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SOME POINTS
IN THE
SURGERY OF THE BRAIN AND ITS
MEMBRANES
.»-
SOME POINTS
IN THE
SURGERY OF THE BRAIN
AND ITS MEMBRANES
CHARLES A. BALLANCE
M.V.O., M.S., F.R.C.S.
ROYAL PRUSSIAN ORDER OF THE CROWN
CORRESPONDING MEMBER OF THE SOCIETY OF SURGERY OF PARIS
SURGEON TO ST. THOMAs's HOSPITAL AND TO THE NATIONAL HOSPITAL
FOR THE PAR.ALYSED AND EPILEPTIC, OUEEN SQ_.
PRESIDENT OF THE MEDICAL SOCIETY OF LONDON, ETC.
WITH ILLUSTRATIONS
iLontion
MACMILLAN AND CO., Limited
NEW YORK : THE M.ACMILLAN COMPANY
1907
All rights reseyved
^^os-d
/^ a-/^-7
PREFACE
This little book contains the material prepared
for the Lettsomian Lectures of the Medical
Society of London for 1906. The short time
devoted to a lecture, and the large amount of
material available for each one, made me decide
to give the Lectures as lantern demonstrations.
Previous to 1906 the Lettsomian Lectures have
been delivered for fifty-five years. It is interest-
ing to note that the subject chosen by me had
never before been selected by a Lettsomian
lecturer.
I heartily thank the many friends v^ho have
been willing to let me have the use of their
illustrations. I thank Dr. Charles Green for
looking up many cases for me, and my brother,
Hamilton Ballance, for the illustrations and notes
of specimens in the Norwich Museum.
Since the Lectures were delivered some cases
have been brought up to date, and a few have
been added.
Fresh from a visit to the great hospitals and
vi . SURGERY OF THE BRAIN
laboratories of Philadelphia and Baltimore, I am
impelled to express my admiration of the splendid
work accomplished and in progress by the dis-
tinguished members of the Philadelphia School
of Neurology, and by Dr. Harvey Gushing of
Baltimore.
It is my hope that these Lectures may be of
service to many friends and other medical men
who do not claim to be expert neurologists.
CHARLES A. BALLANCE.
September 1906.
CONTENTS
LECTURE I
Reminiscences of Dr. Lettsom — Some Points in the
Surgery of the Cerebral Membranes
Anatomical, physiological, and physical considerations — The sub-
dural and sub-arachnoid spaces — The cerebro-spinal fluid —
Subdural haemorrhage in adults and infants — Traumatic
encephalocele — Pathology of meningeal infections — Subdural
and sub-arachnoid suppuration — Varieties of meningitis —
Symptoms and diagnosis — Surgical treatment of tubercular and
suppurative meningitis and of hydrocephalus interna . Page
LECTURE II
Some Points in the Surgery of Abscess of the Brain
Etiology — Morbid anatomy and pathology — Infection of brain
substance — Manner of development, form, and situation —
Clinical evolution — Symptoms and diagnosis — Complications
— Operative treatment of the varieties of abscess — Recent im-
provements in details — Concluding remarks . . Page 87
LECTURE III
SoM-E Points in the Surgery of Tumour of the Brain
Diagnosis — Difficulty of localisation — Symptom complex — Absence
of all symptoms — Localisation symptoms — Relation of injury
to tumour growth — Tumours of the cranium, the meninges,
and the brain — Tubercular and syphilitic tumours — Endo-
thelioma— Fibro-sarcoma — -Glioma, solid and cystic — Sarcoma
— Psammoma — Cysts — Secondary tumours — Treatment with-
out operation — Operations, curative and palliative — Pioneer
work of the past, the present position, and future outlook Page 156
INDEX
397
Vll
ILLUSTRATIONS
FIG.
I.
2.
3-
4-
lO.
1 1.
12.
13-
H-
17.
18,
20.
2 1.
23-
John Coakley Lettsom, M.D., LL.D., F.R.S. .
John Fothergill, M.D., F.R.S. .
Garden view of Dr. Lettsom's house at Camberwell
Destitute family relieved as a result of one of Dr. Lett
som's morning walks in the Metropolis
Anterior part of cisterna magna distended by artificial in
jection .....
Anterior part of cisterna magna distended with pus
Posterior basic meningitis
The brain stem .....
Portion of aorta of turtle {Chelonia Mydas) showing capa-
cious lymphatic sheath surrounding the artery .
Dissection of head of turtle, with brain stem exposed
The brain stem in the embryo .
Diagram of subdural hematocele
Photograph of the outer surface of the tumour
16. Intracranial hemorrhage of the new-born
Sketch of operation for arachnoid cyst
19. Simple fracture of skull in infants
Traumatic meningocele .
Fracture of right frontal bone in a new-born infant, frac
ture extending into orbit
I. Traumatic meningocele before operation. 2. Same
case after operation ....
Diagram of fracture of skull in Dr, Bastian's case of trau
matic encephalocele ....
ix
PAGE
2
13
13
13
16
20
21
22
23
23
32
33
34' 35
36
37
37
38
X SURGERY OF THE BRAIN
FIG.
24, 25. Lumbar puncture ....
26. Sub-arachnoid space between the convolutions .
27. Sketch of complete mastoid operation
28. Arrangement of membranes around spinal cord .
29. Arrangement of arachnoid in the region of the cauda
equina .....
30. The relation of the frontal sinuses to the frontal lobes
31. The relation of the accessory sinuses to the base of the
skull ; viewed from the cranial cavity .
32. Radiogram of large frontal sinuses
33. Radiogram of suppurative disease (granulation, polypi, and
pus) in the left frontal sinus .
34. Result six weeks after the Killian operation for frontal
sinus suppuration
35. Miliary tuberculosis of pia covering the convexity of the
brain ......
36. General suppurative meningitis .
37. Posterior basal meningitis
38. Diagram of subdural drainage by an angular metal tube
39. Congenital hydrocephalus in an infant of 6 months
40. Congenital hydrocephalus treated by ligation of both
common carotid arteries
41. Traumatic meningo-cortical abscess of brain
42. Spreading septic softening of the right frontal lobe
43. Encysted abscess of left frontal lobe
44. Abscess of the right temporo-sphenoidal lobe
45. 46. The cortical centre for hearing
47, 48. The cortical centres for taste and smell
49. Diagram of the position in the cerebral cortex of th
centres concerned in the mechanism of speech
50. Tumour of the 3rd temporal convolution, indicating th
position of the naming-centre .
51. Case illustrating site of naming centre
52. Tumour of the right temporo-sphenoidal lobe bearing on
the localisation of the sense of smell
PAGE
44. 45
47
49
51
51
65
65
(^1
72
74
11
78
82
83
89
100
lOI
105
108
109
1 12
1 12
113
121
ILLUSTRATIONS xi
FIG. PAGE
53. Abscess in the temporal and frontal lobes . .124
54. Two abscesses in the brain . . . .133
55-57. Illustrating case of two abscesses in the cerebellum . 142
58. Frontal lobe abscess secondary to frontal sinus disease . 144
59. Abscess of cerebellum occupying the anterior and inner
part of the left hemisphere .... 145
60. Drawing to show the direction in which the complete
mastoid operation should be extended in order to drain
a cerebellar abscess through its stalk . . .146
61. Coronal section of left cerebral hemisphere, with small
temporo-sphenoidal abscess . . . .147
62. Glioma of frontal lobe . ^. . . .159
63. Cholesteatoma vera of cerebellum . . . 160
64. Endothelioma of meninges of temporal lobe . .161
65. Carcinomatous deposit in centrum ovale, secondary to
growth in oesophagus . . . . .161
66. Carcinomatous deposit in the skull, secondary to Scirrhus
mammae . . . . . .162
67. Sarcoma ot brain (multiple growths), secondary to sarcoma
of lung . . . . . .163
68. 69. Simple cyst of cerebellar hemisphere . 164, 165
70. Hydatid of right frontal lobe . . . .166
71. Hydatid of right lateral ventricle removed through post-
Rolandic region . . . . .166
72. Aneurism of the intra-cranial portion of the left internal
carotid artery . . . . . .167
73-76. The establishment of a cerebral hernia as a decom-
pressive measure for inaccessible brain tumours . 171
77. Exposure of cerebellum (R. hemisphere) by the usual
method . . . . . .172
78. Tumour of the brain with a long history and with few
symptoms . . . . . .178
79. Photograph of psammoma (angeiolithic sarcoma) of occi-
pital lobe . . . . . .180
80. Microscopical section of tumour . , .180
81. Patient fourteen months after operation for cerebellar
tumour . . . . . . . 191
Xll
SURGERY OF THE BRAIN
82, 83. Back and side views of head, two years and nine
months after operation for cerebellar tumour . 198, 199
84, 85. Healed fracture, outer and inner surfaces of skull,
over gliomatous tumour in occipital lobe . .201
86. Cystic glioma of occipital lobe under healed fracture of
skull ....... 201
87. Photograph of supposed meningo-cortical abscess . 205
88. Tumour of frontal lobe following punctured fracture of
skull ....... 205
89-95. Illustrating the histology of the tumour . 206-210
96, 97. Parosteal round-celled sarcoma of the squama . 222
98. Periosteal sarcoma of squama .... 222
99. Cavernous angeioma (without sarcoma cells) of os frontis
projecting backwards into skull cavity and compressing
frontal lobe . . . . . .223
100. Sarcoma of orbital part of os frontis displacing dura and
brain . . . . . .223
10 1. Sarcoma of outer aspect of dura mater compressing lett
frontal lobe ...... 224.
102. Sarcoma of outer aspect of dura . . . 224
103. Fibrosarcoma of cerebellar meninges . . . 225
104. Tumour (? endothelioma) of meninges in frontal region 226
105. 106. Endothelioma of meninges in frontal region . 227
107. Sarcoma ossis frontalis before and after operation . 228
108. Destruction of skull by malignant disease . . 228
109. Epithelioma of frontal region .... 229
I 10. Carcinoma of frontal region . . . . 229
111. Photograph of a child, aged 5 years, showing position of
head assumed in a lesion of the right lateral lobe of
the cerebellum . . . . . 234.
112. Child with right cerebellar tumour (solitary tubercle) . 235
113. Skew deviation of the eyes .... 247
114. Bulging right occipital fossa in a child ^h years . 250
115. Simple cyst of left cerebellar hemisphere . . 252
116. Photograph of cast of back of head, showing bulging
left occipital fossa . . . . .255
ILLUSTRATIONS
Xlll
FIG. PAGE
117. Illustration of solitary tubercle removed from left
occipital fossa with success . . . .255
118, 119, The patient fifteen months after operation . 257
120. Hemorrhage tearing up left cerebral hemisphere . 261
121. Fibro-plastic tumour of Lebert . . . . 263
122. Fibro-plastic tumour of cerebellar meninges . . 263
123. Fibro-sarcoma of cerebellar meninges . . . 264
124. Tuberculous tumour of the cerebello-pontine angle . 264
125. Upper surface of cerebellum, showing a solitary tubercle
in each hemisphere ..... 265
126. Endothelioma of cerebellum .... 265
127. Solitary tubercle of cerebellum . . . 266
128. Simple cyst of cerebellum .... 266
129. Spindle-celled sarcoma of the auditory nerve . . 267
130. Tumour of left auditory nerve . . . . 268
131. Endothelioma of cerebellar meninges . . . 269
132. Glioma filling fourth ventricle .... 270
133. Fibroma growing from the left acoustic nerve . . 271
134. A tumour the size of a bantam's egg, of a firm fibrous
consistence, in the left cerebello-pontine space . 272
135. Neurofibroma of the right acoustic nerve . . 273
136. Encapsulated sarcoma of the cerebellar meninges com-
pressing upper surface of vermis . . . 274
137. Fibro-sarcoma of left cerebellar hemisphere . . 275
138-144. Case of fibro-sarcoma of cerebellar meninges 276-281
145-148. A case of compound comminuted fracture of the
skull and laceration of the brain . . 282-285
149. Operation for simultaneous exposure of both cerebellar
hemispheres, necessitating ligation of the occipital
sinus ....... 286
150. Structures in relation to the anterior aspect of the cere-
bellar hemisphere and the posterior surface of the
petrous ...... 286
151. The reindeer of the cave of Thayngen, near Schafi--
hausen ...... 288
152. Perforated antler discovered in the cave of La Madelaine 289
XIV
SURGERY OF THE BRAIN
153. Right cerebral hemisphere from a human foetus in the
latter half of the 6th month of development . . 289
54. Sarcomatous solid tumour of (?) optic thalamus . 292
55. Spreading oedema of the centrum semi-ovale, from a
small nodule in the right prefrontal cortex, secondary
to a renal carcinoma ..... 293
56. Areas and centres of the lateral aspect of the human
hemicerebrum ..... 295
57. Areas and centres of the mesial aspect of the human
hemicerebrum ..... 295
58. Horizontal section of the occipital lobe, showing the
optic radiation . . . . .301
59. Glioma of occipital lobe .... 303
60. 161. Symmetrical atrophy and degeneration of the
occipital lobes ..... 306
62. The distribution of the middle meningeal artery . 308
63. Fibro-plastic tumour of cerebral meninges . . 308
64. The motor area and its subdivisions on the lateral
aspect of the hemicerebrum of the chimpanzee . 310
65. The motor areas and centres on the mesial aspect of the
hemicerebrum of the chimpanzee . . .310
66. Glioma of frontal lobe, microscopical section. . . 315
67. Glioma of frontal lobe . . . .320
68-170. Large glio - sarcoma of frontal lobe successfully
removed . . . . . .321
71-174. Illustrating a case of subcortical tumour . . 322
75-182. Illustrating a case of malignant growth of frontal
lobe perforating dura and skull . . 324-329
83, 184. Symmetrical cortical lesions causing hallucinations
of hearing, word deafness, and sensory aphasia . 350
85. Sketch of operation for subcortical tumour (sarcoma),
growing in the centrum ovale beneath the cortex of
the upper part of the precentral convolution and the
superior parietal lobule . . . ,352
186-189. Illustrating the usual method of making the scalp
flap, and the drainage of a malignant "cyst" . -355
ILLUSTRATIONS
XV
190. Diagram of site of tuberculous tumour behind tlie central
fissure ....
355
367
370
370
191. Large sarcoma of cerebral meninges
192. Large tumour of left parietal region
19^. Radiogram of the tumour
194-198. Tumour of frontal lobe without optic neuritis 381-385
199. Microscopical section of growth found between dura of
posterior fossa and temporal bone . . .387
200-201. Microscopical appearances of frontal lobe tumour
described under Figs. 175-182 . . 388, 389
202-206. Large sarcoma of outer surface of dura mater 392-396
LECTURE I
REMINISCENCES OF DR. LETTSOM SOME POINTS" IN
THE SURGERY OF THE CEREBRAL MEMBRANES
Anatomical, physiological, and physical considerations — The sub-
dural and sub-arachnoid spaces — The cerebro-spinal fluid —
Subdural hsemorrhage in adults and infants — Traumatic
encephalocele — Pathology of meningeal infections — Subdural _
and sub-arachnoid suppuration — Varieties of meningitis —
Symptoms and diagnosis — Surgical treatment of tubercular and
suppurative meningitis and of hydrocephalus interna.
It is my duty, as it is my pleasure, to gratefully
acknowledge the honour which the Council of
the Medical Society of London has conferred
upon me by inviting me to deliver the Lettsomian
lectures.
'Reminiscences of Dr. Lettsom.
These lectures were founded to commemorate
a great physician who, a century ago, was a leader
of medical practice in London. It therefore
seems only right briefly to recall something of
his life and work before entering upon the
subject matter of the lectures^
B
2 REMINISCENCES OF
John Coakley Lettsom came of a Quaker
family. He was born in 1744 in the West
Indies, and died in London in 18 15.
Sent at an early age to England to be educated,
he chose medicine as his profession, and, in
accordance with the custom of the time, was
apprenticed, the master selected for him being
Fig. I.— John Coakley Lettsom, M.D., LL.D., F.R.S.
a Mr. Sutcliff then practising at Settle in York-
shire. After his apprenticeship he attended
St. Thomas's Hospital, where he was most
diligent in his observation of the patients, of
whose cases he made notes, a custom not then
usual.
His first practice was in the West Indies.
He had returned to the place of his birth to
claim the residue of a property left to him by
DR. LETTSOM 3
his father. It consisted of a portion of land and
some fifty slaves ; these latter he promptly
emancipated, slavery being altogether repugnant
to his nature.
He thus found himself dependent upon his
profession for support, and commenced practice
in Tortola. It is recorded that " in five months
he amassed two thousand pounds," a financial
success attending the early effbrts of very few. He
gave half this sum to his mother, and with
the remainder returned to England in September
1768.
He spent several months visiting the Univer-
sities of Edinburgh, Paris, and other centres of
learning, and took the degree of M.D. at the
University of Leyden.
Soon after graduating he returned to London,
and commenced practice in the City under the
patronage of Dr. John Fothergill. His success
was early and complete, and it is stated that for
a number of years he enjoyed the largest practice
in the City of London.
Of this Society he was one of the original
Fellows. The memoirs of the Society bear
witness to the prominent part he took in its
discussions, while the freehold property from
which we still derive a revenue attests the
generosity of his benefactions.
4 REMINISCENCES OF
He was no less celebrated for liberality of
mind and benevolence than for his skill as a
physician.
The following is one of the more extra-
ordinary instances of his generosity. He was
attacked and robbed by a highwayman, but far
from bearing any resentment, he gave the man
Fig. 2.— John FothergiU, M.D., F.R.S.
his address, and offered him further assistance.
The robber responded to this invitation, and
Lettsom succeeded in obtaining for him from
His Majesty a commission in the army, and he
served the country with distinction.
Lettsom was a voluminous writer, and did not
confine himself to medical subjects. His non-
medical writings were chiefly upon matters of
public utility or on philanthropy, such as the
properties of the tea-plant, the cultivation of the
DR. LETTSOM 5
mangel-wurzel, the abolition of slavery, and the
relief of the poor.
He was not learned in the highest acceptation
of the term, yet he was the friend and the patron
of learning. Wherever his influence extended —
and it was not narrowly circumscribed — science
and useful literature flourished.
He was particularly keen on exposing quacks.
On one occasion he insisted on a post-mortem
examination as a " urine caster " had asserted
that the disease which had caused death was in
the kidneys, whereas Lettsom maintained that
the symptoms — headache, vomiting, slow pulse,
and vertigo — were due to disease of the brain.
The autopsy showed healthy kidneys, and inflam-
mation within the skull, probably the result of
a former injury.
His correspondence was extensive, and many
remarkable letters have been preserved, which
show the variety of subjects in which he took
interest, and afford many evidences of his kindly
and sympathetic nature.
The amenities of medical life appear to have
somewhat differed, in their forms of expression
at least, from those of the present day. It is
recorded that Lettsom was much angered by the
discourtesy of Mr. Baker, one of the surgeons ot
the hospital. Mr. Baker had a son who suffered
6 REMINISCENCES OF
from epilepsy, which somewhat impaired his
understanding. His medical colleague Dr.
Akenside inquired to what study he proposed
to place him ; Mr. Baker replied, " I find he
is not capable of making a surgeon, so I have
sent him to Edinburgh to make a physician of
him."
Another instance of the manners of the times
is afforded by the well-known ungenerous epi-
gram written of Lettsom —
When patients come to I,
I purges, bleeds, and sweats 'em.
If after that they choose to die.
What's that to I,
I lets 'em.
Lettsom undoubtedly earned a handsome pro-
fessional income, but the extent to which his
private fortune must have been injured by his
generosity to others may be gathered from one
of his letters, dated i8th February 1783. Reply-
ing to an intimate friend who had upbraided him
for neglecting to take any adequate relaxation,
he says, *' I have a weakness which I cannot
overcome. I hope and believe it does not result
from ambition or from vanity ; but so it is, how-
ever, that if I hear of want, I often distress
myself to obviate that want. In looking over
my expenses since January last, I find I have
DR. LETTSOM
7
expended above six hundred pounds in donations ;
and, like a necessitarian, I have no power to con-
trol this extravagance. Thus with an income of
^5000 per annum I am always involved ; and
what is still more alarming, my pensioners
increase daily. I mention my extravagance as
an excuse for my perpetual application to busi-
FiG. 3. — Garden view of Dr. Lettsom's house at Camberwell.
ness ; for since the year 1769, when I first
settled in London, I have not taken one half-
day's relaxation, and I cannot get to Grove Hill
above once a fortnight."
Though there were no death duties in his
time, he distributed his wealth during his life —
a form of charity much more real than that
commonly practised of distributing after death
what can no longer be retained.
The story of the rescue of a starving family
as the result of an early morning walk is typical
8
REMINISCENCES OF
of Lettsom's life. This family was saved from
starvation, and with the co-operation of the
churchwarden of I>ittle Greenwich in Bishops-
gate Street was given a new start in life.
Lettsom writes " that he has experienced how
3^6»,
Fig. 4. — Destitute family relieved as a resvilt of one of Dr. Lettsom's morning
walks in the Metropolis.
greatly the sight of real misery exceeds the
description of it," and again
To pity human woe,
Is what the happy to the unhappy owe.
Physician, student of nature, and philan-
thropist, Lettsom passed into the silent world,
leaving behind him a host of friends and a name
ever to be associated with boundless private
charity and numerous projects for the public
weal.
DR. LETTSOM
Of Lettsom it may be truly said —
To live in hearts we leave behind is not to die ;
and,
The souls of the risihteous are in the hand of God.
In this lecture I propose to consider the posi-
tion of surgical intervention in the disease, or
rather group of diseases, having for anatomical
basis a lesion of the meninges.
Anatomical^ Physiological^ and Physical Observations.
The Subdural and Sub-Arachnoid Spaces.
We are all familiar w^ith the three-fold mem-
branous investiture of the central nervous system,
but the special importance of certain anatomical
details is less well understood.
Axel Key and Gustav Retzius in 1875 pub-
lished the result of several years' research in a
beautiful monograph, w^hich, as Charpy says, has
remained the classical work on this subject,
though their results have not been confirmed
(or corrected) by subsequent workers.
Key and Retzius showed : —
I. That there is no gross communication
between the subdural and the sub-arachnoid
spaces.
10 SOME POINTS IN THE SURGERY
2. That the sub-arachnoid and the subdural
spaces of the brain can be completely injected
from the corresponding spinal spaces.
3. That fluids injected separately into each of
these spaces mix in the subdural space of the
Pacchionian bodies, then pass on into the venous
sinuses, and even reach the veins of the scalp,
4. That injection of the sub-arachnoid space,
after death or during life, at a low pressure shows
that at the base of the brain it is broken up into
certain definite spaces of considerable capacity,
and that over the cerebral hemispheres the sub-
arachnoideal mesh-work is more abundant in the
sulci than over the tops of the convolutions, so
that these latter, as another writer has aptly
expressed it, stand out from the general injection
mass like the hedges of a flooded land.
5. That the blood -pressure in the cerebral
sinuses, though diminishing during inspiration,
is always positive, and that the pressure of the
cerebro-spinal fluid in the sub-arachnoid space
always exceeds by a few mm. of Hg. the cere-
bral venous pressure, and that therefore the flow
of fluid is from the sub-arachnoid space into the
venous system. As the specific gravity of the
cerebro-spinal fluid is less than that of the blood,
any flow determined by osmosis would be, in the
main, in the same direction.
OF THE CEREBRAL MEMBRANES ii
As the result of his own researches, Leonard
Hill maintains that the sub -arachnoid space is
" chiefly a potential rather than an actual space,
except in those few places where inequalities of
the brain surface are rounded off by small col-
lections of fluid beneath this membrane," and
that " the living brain with its circulating blood
almost entirely fills the cranium, and the fluid
that moistens its surfaces is little more in amount
than the synovial fluid in a joint."
This latter statement is certainly true of the
subdural cavity, but is less clearly applicable
to the sub-arachnoid space ; and when it is
stated that "the plates in Key and Retzius' mono-
graph, which are copied into most anatomical
works of to-day, give an entirely erroneous idea
of the contents of the cranium in the living
animal " ; it seems desirable to point out that
these authors made their injections shortly after
death, and do not suggest that the spaces are
normally distended to the same degree during
life, and that they controlled their results ob-
tained from injections on the cadaver by ex-
periments on living animals. It must not be
forgotten that however little fluid there may be
in the sub - arachnoid cavities at a particular
moment during life, yet a considerable amount
is present in the ventricles with which the
12 SOME POINTS IN THE SURGERY
sub-arachnoid cavities are in direct communica-
tion.
The well-known figure of Key and Retzius,
showing the sub-arachnoid spaces fully injected
as they appear in a vertical median section of
the head, was expressly intended to represent
the relationship " of the various parts of the
brain when the ventricles and the sub-arachnoid
space were distended with fluid." The blood-
pressure being nil, the injection would displace
most of the blood from the vessels of the pia,
driving it at least as far as the venous sinuses,
and the sub -arachnoid spaces would therefore
appear exaggerated. Artificial distension by
injection is a usual and well-known method
of anatomical demonstration. For example, it
would scarcely be contended that Sappey's illus-
trations of the lymphatics, as demonstrated by
injection with mercury, were intended to repre-
sent their normal state of distension during life.
Whatever the normal condition of the sub-
arachnoid spaces may be, they certainly become
distended during life with blood or purulent
efi\isions ; of this any one who has attentively
made a few post-mortem, examinations must be
convinced.
In the illustration of posterior basal menin-
gitis published by Dr. Lees and Sir Thomas
OF THE CEREBRAL MEMBRANES 13
Fig. 5. — Anterior part of cisterna magna distended by artificial injection.
(Key and Retzius.)
The injection was made into the sub-arachnoid space of the spinal theca. The
injection has penetrated everywhere beneath the arachnoid, in the interpeduncular
space, and in the sulci between the convolutions.
Fig. 5. — Anterior part of cisterna magna distended
with pus. (Lebert, i85i.)
From a case of suppurative meningitis in a soldier aged
24 years. Death on the fourth day. The onset was
sudden, and the symptoms were fever, shivering, severe
occipital pain, prostration, delirium, and finally coma.
Fig. 7. — Posterior basic menin-
gitis. (Lees and Barlow.)
Child aged 5 months. Dura-
tion of illness 1 1 days.
The dark shading indicates the
sites of pus collection under the
arachnoid. The anterior part of
the cisterna magna was distended,
and pus was also present over the
tips of the temporo -sphenoidal
lobes.
14 SOME POINTS IN THE SURGERY
Barlow, the anterior part of the cisterna magna
is seen distended with pus, just as one of Key and
Retzius' figures shows it distended artificially by
injection.
It is a common surgical experience — for
example, in operating to relieve optic neuritis —
that it is easy to obtain a flow of fluid from the
sub -arachnoid space of the base of the brain
while it is almost impossible to do so from the
vertex — opening the subdural cavity is for such
a purpose a useless measure.
The only place at which, from the figures
of Key and Retzius, it would be reasonable to
infer that a considerable flow of cerebro-spinal
fluid would be obtained is below the cerebellum.
It is just here that the surgeon most easily
obtains a rush of cerebro-spinal fluid and is able
to establish drainage.
Imbert, in 1884, wrote: "The principle of
Archimedes, in conjunction with that of Pascal,
explains the manner in which certain fluids of
the animal economy aflbrd protection to the
organs immersed therein. The brain, for ex-
ample, loses 98 per cent of its weight when
immersed in cerebro-spinal fluid, for the differ-
ence in specific gravity between the brain and
the fluid is only 0.02. A brain which would
weigh 1 500 grammes in air would only weigh
OF THE CEREBRAL MEMBRANES 15
30 grammes in the cerebro- spinal fluid : it is
this weight, then, of 30 grammes which
represents the whole pressure of the brain on
the base of the skull. So feeble a pressure,
scarcely amounting to i decigramme per square
centimetre, would neither damage the extremely-
delicate texture of the nervous centres nor offer
the least resistance to the circulation of the
blood in the interior of the brain. Further,
fluid interposed between the brain substance
and the cranium lessens the effect of blows and
external shocks by spreading compression pro-
duced at any one point over the whole surface
of the brain, in accordance with the law that
pressure is equally distributed in all directions."
Though it cannot be admitted that the
physical conditions are anything like so simple
as Imbert's description would lead us to believe,
yet the almost constant escape of the brain stem
in injuries of the head points conclusively
to the existence of some special protective
mechanism.
The sub-arachnoid cisternas, partitioned off as
they are so that fluid only slowly escapes from
one into another, are well fitted to act as a kind
of hydraulic buffer, and notwithstanding the
view that the sub-arachnoid space is a potential
space only, it would appear that the cisternas are
i6 SOME POINTS IN THE SURGERY
of importance in protecting the isthmus cerebri
from injury.
The weight of the brain is not wholly, or
even to any considerable extent, supported by
hydrostatic pressure ; its anterior and posterior
extremities rest upon
planes inclined in op-
posite directions, viz.
the orbital plate of the
frontal bone and the
tentorium cerebelli ;
the middle lobe fits
with great accuracy
into the middle fossa,
and the falx cerebri
prevents any side-to-
side movement of the
hemispheres ; a very
thin layer of fluid
would in ordinary
circumstances prevent any injurious shock from
impact of the brain substance against the resisting
bone.
From the mass of the hemispheres the
isthmus cerebri passes almost vertically down-
wards, its lateral displacement is prevented by
the sheaths of the nerves issuing from it and
by bands of sub-arachnoid connective tissue, and
Fig. 8. — The brain stem.
(Key and Retzius.)
Note the sub-arachnoid trabeculae which
prevent movementof the brain stem against
the foramen magnum.
OF THE CEREBRAL MEMBRANES 17
the amount of fluid by which it is surrounded is
sufficient to give material mechanical support.
It is to the parts below the tentorium that
Imbert's purely physical statement of the con-
ditions present more closely applies.
Hill's experiments led him to conclude that
though the amount of blood in the arteries or
veins of the brain may and does vary consider-
ably, the absolute amount of blood within the
cranium does not vary to any great extent, the
observed circulatory variations being variations
in the distribution of blood and not in its
total amount, and the atmospheric pressure
being the chief factor in maintaining these
conditions.
Sir Thomas Watson in the fifth edition of
his Pj^actke of Physic observed that he formerly
taught this view, and mentioned some experi-
ments by Munro and Kelly which led him,
though with some hesitation, to accept it ; the
experiments of Burrows, however, convinced
him that it was erroneous.
It would certainly be thought that if the
atmospheric pressure exercised so considerable
an influence on the cerebral circulation this
would be profoundly modified when the dura
or even the skull was opened ; surgeons do
not, however, observe any profound change in
1 8 SOME POINTS IN THE SURGERY
the condition of the patient at the moment of
opening the skull.
No more marked disturbance of the circula-
tion is observed on opening the skull than on
opening the peritoneum ; when the surgeon
incises the dura mater there are no phenomena
comparable to those occurring when the normal
parietal pleura is incised.
The Cerebrospinal Fluid
The cerebro-spinal fluid is a secretion and not
an exudation. Mott has recently laid stress on
this point. He writes : " It is comparable to the
amniotic fluid and the sweat for true albumin
and fibrinogen are absent. (It may be noted
here that one function of the amniotic fluid is
protection.) At each cardiac systole it is driven
from the cranium into the spinal canal. (This
may in part explain the presence of blood
and pus in the spinal theca when purulent and
hasmorrhagic effusions occur within the cranium.)
A layer of arachnoid like a sieve follows the
pial vessels as they dip into the brain, and thus
forms a perivascular canalicular system. The
vessels are therefore always surrounded by a
constant fluid pressure." The cerebro-spinal
fluid is of course not lymph, but these arachnoid
OF THE CEREBRAL MEMBRANES 19
sheaths play a part in the brain that is elsewhere
the sole function of the lymph sheaths. In this
manner oxygen, which is necessary for the bio-
chemical changes of nervous tissue, is probably
carried by the cerebro-spinal fluid to all parts of
the central nervous system.
On examining the great lymph sheath around
the aorta of the turtle in the Royal College of
Surgeons Museum, it occurred to me that it
would be interesting to examine the membranes
around this creature's brain. It will be noticed
that the cranial subdural cavity of the turtle is
not a potential but an actual space, and that
delicate connective tissue bands cross it, as in the
sub-arachnoid space of man, to prevent displace-
ment of the brain stem (Figs. 9 and 10).
Hamatoceie of the Subdural Cavity in Adults
and Infants. Traumatic Cephalhydrocele and
Enceplialocele.
It has already been pointed out that the
subdural and sub - arachnoid cavities are often
defined and distended by effusion of blood
following injury. Time will not allow a full
discussion of this subject, but reference may
briefly be made to cases in which a blow
on the head or a fall is followed at some
20 SOME POINTS IN THE SURGERY
distance of time by obscure cerebral symptoms,
among which mental disturbance and transitory
paralysis are prominent ;
in some such instances a
considerable haemorrhage
has taken place into the
arachnoid cavity, the blood
has become encysted, and
like a blood collection in
the tunica vaginalis, has
continued to increase in
size, causing slow pressure
on the brain.
I successfully removed
such a cyst, which mea-
sured seven inches in its
long diameter, four and a
half in its short, and one
and a half in thickness,
from a man aged thirty-
four years, a patient of
Dr. James Taylor, who had
^'?r?T^°''.'i"'^1 T'-°^'"'^' narrowly escaped being:
[C/ielonia Mydas) showing capa- J L O
cious lymphatic sheath surround- pnnc;io-nprl fo 3 ^UU^Ur
ing the artery.— (R.C.S. Museum, COUblgnCQ lO a lUUdllC
Pkvsiolozkal Series, No. SS"? c.) i i i • -i ,
^ ^ asylum, where he might
possibly have been labelled " general paralysis "*
and died without relief (Figs. 12 and 13).
The following two cases of operation for
OF THE CEREBRAL MEMBRANES 21
subdural hasmorrhage I have not previously
published : —
C. K., female, aged twenty -six years. Admitted
December 21, 1904, into the National Hospital under
Dr. Ferrier.
History (obtained from husband). — No neuroses
in family. Married eighteen months. Now five
Fig. 10. — Dissection of head of turtle, with brain stem exposed.
Note the trabecula of areolar tissue crossing the wide subdural space to prevent
displacement against the surrounding rigid brain case.
The turtle heads were kindly supplied by Messrs. Buszard of Oxford Street.
months pregnant. No history of injury. A month
ago her husband was leaving home in the morning for
his work when he heard a cry, and on going back
found his wife shrieking and in a demented condition.
She was violent, and tossed herself about. Next day
condition much the same, but some weakness of right
arm was noticed. She continued screaming, with
intervals, during which she would repeat meaningless
combinations of words, or point to things seen by
22 SOME POINTS IN THE SURGERY
herself apparently of a terrifying description. She
remained in this state for a month. Recently paresis
of right leg had been noticed.
On admission. — Patient lies on her back continually
crying out and waving her left arm. She does not
seem to recognise objects presented to her. On being
J
.^^'
Fig. II. — The brain stem in the embryo.
Fig. 11 a. — Drawing of section of head of human embryo (about four months).
( X 2). A large space is seen between the brain stem and the skull. In this space
the basilar artery can be recognised lying nearer the brain stem than the skull. The
space is crossed by delicate bands of embryonic connective tissue.
Fig. lib represents a portion of the same specimen as seen under a one-inch
objective. The basilar artery and the connective-tissue bands are more plainly shown,
and fine vessels can be seen penetrating deeply into the brain substance.
The specimen was prepared by Dr. Charles Green, who kindly allowed me
to use it.
moved she utters loud cries. When not crying she
lies in an exhausted semi-comatose condition. She has
double optic neuritis, but is able to see. Pupils normal.
Marked weakness of right side of face ; complete flaccid
paralysis of right arm, and nearly complete paralysis of
right leg. Left arm moves well. Abdominal reflexes
absent on right side. Knee-jerk brisk, and ankle clonus
OF THE CEREBRAL MEMBRANES 23
present on right side. Urine retained ; fasces passed
unconsciously.
Operation, December 24, 1904.- — ^The patient has been
Fig. 12. — Diagram of subdural haematocele. (Taylor and Ballance.)
Horizontal section showing the position of the " cyst " and the compression of
the cerebral hemisphere, and explaining the occurrence of expansile pulsation in the
tumour. The marks * * show the extent of the opening in the skull. The tumour
being fluid, the pulsations of the brain were transmitted in every direction ; hence
when the finger and thumb grasped the centre of the tumour (see arrows in the
centre of the cyst) they were separated by an expansile pulsation comparable to that
which obtains in aneurysm.
kept quiet under morphia ; she is more exhausted and
her pulse is weaker. The left motor area was exposed.
A subdural hasmatocele compressing the Rolandic area
Fig. 13. — Photograph of the outer surface of the tumour. (Taylor and Ballance.)
(R. C. S. Museum, No. 3837 a.)
An opening has been made in the cyst wall, which exposes in the specimen a
deep red clot.
was found. It extended forwards to the frontal pole
and downwards towards the base, and was half an inch
thick. It was removed without difficulty. Patient was
24 SOME POINTS IN THE SURGERY
much better after the operation, and all went well for
ten days. On January 7 pneumonia supervened, and
the patient died on January 10. There had been a
little blood noticed on the dressings for a few days.
This had come from cortical vessels, possibly those
which had furnished the blood of the hematocele.
W. M,, male, aged forty-eight years. Admitted on
March 28, 1906, into the National Hospital under Dr.
Ormerod.
The family history was good ; no epilepsy nor other
neuroses could be traced in it. The patient denied having
had venereal disease, but admitted having incurred
the risk of contracting it. He had worked hard and
had had recent mental worries. Much head work, but
no manual labour. In May 1905 he was struck hard
on the right side of the head by the falling lid of a
flush tank ; he did not lose consciousness. Since then
he has suffered from headache on waking in the
morning. In February 1906 he had an illness thought
to be influenza, and was sick once or twice without
obvious cause. Since then he has had headache, occipital
and retro-ocular. When he gets out of bed his sight
becomes temporarily blurred ; he has diplopia occasion-
ally. No definite giddiness. Has vomited six times
since the " influenza." Sight has been worse during the
last four weeks. The symptoms have varied. A week
before admission he was thought to be better.
On admission. — Is slightly emotional ; cerebration
slow ; takes some time to answer even simple questions.
No alteration of smell, taste, or hearing. Sight much
impaired ; reads one inch letters at four feet. No
hemianopsia ; fields not contracted. (Rough test only).
Optic Discs. (Mr. Gunn.) Right : Intense fungiform
OF THE CEREBRAL MEMBRANES 25
papillitis with numerous hasmorrhages. Highest point
seen with +9D. Left: Same as right. Highest
point seen with +9.5 D. Pupils normal.
Tongue when protruded deviated slightly to left.
Complains of dull, constant headache, occipital, retro-
ocular, and frontal. No weakness of face or arms.
Cremasteric reflex difficult to obtain on left side.
Patellar and ankle reflex more brisk on left than on
right side. Ankle clonus well marked on left, slight
on right side. Gait feeble and slightly unsteady. No
tenderness of cranium.
Operation in two stages. Bone removed over right
frontal lobe. On opening the dura a thin layer of clot
enclosed in a membrane found over the whole convex
surface of the right hemisphere, from frontal to occipital
region. This was removed. A cortical vein in the
frontal area bled a good deal ; apparently it was
attached to the clot capsule, and may have been the
cause of the subdural haemorrhage. The clot was
thicker (about quarter inch) over the anterior part of
the frontal lobe and over part of the Rolandic area ;
elsewhere it was very thin.
This matter did not escape the astute obser-
vation of Richard Bright, who in 1831 v^rote :
" There is a species of partial accumulation of
fluid in the brain which must not be passed
over without notice : I mean serous cysts
forming in connection with the arachnoid, and
apparently lying between its layers, or attached
by thin adventitious membranes. These are
occasionally discovered on dissection, and have
26 SOME POINTS IN THE SURGERY
either produced no symptoms or have been
quite unsuspected till after death. These cysts
vary in size from the size of a pea to that of a
large orange, and may be considerably larger.
They appear to be of the most chronic character,
and probably never enlarge after their first
formation. The brain is completely impressed
by them, so that when the fluid is let out a
permanent cavity remains, and even the bone of
the skull is moulded to their form."
Two cases are illustrated in Bright's work.
The post-mortem appearances in one of these
are thus described : " On sawing through the
skull-cap a sudden gush of limpid fluid attracted
attention, and examining whence this fluid
escaped, a considerable oblong depression was
found in the middle lobe of the right hemisphere.
On minute inspection the fluid, which amounted
to at least twelve ounces, had been contained in
a cyst formed by the splitting of the arachnoid
membrane, which had pressed on the middle
lobe of the brain, and thus produced a corre-
sponding depression. The membranes and sub-
stance of the brain (with the exception stated)
did not exhibit any morbid appearances. The
thoracic viscera were quite healthy. The abdo-
minal viscera showed no traces of disease, except
extensive ulceration of the ileum and cascum."
OF THE CEREBRAL MEMBRANES 27
The preparation is deposited in the Museum of
the Royal College of Surgeons. The patient, a
male aged eighteen years, had probably died from
enteric fever. No history of injury is given.
In 1897 Biroula showed at a meeting of the
St. Petersburg Anatomical Society a specimen
very similar to that of Bright. The patient, a
soldier aged twenty-four years, died from enteric
fever. A large meningeal cyst was found over
the first and part of the second frontal convolu-
tion on the left side. The brain was indented
by the cyst. The cyst walls were formed by
the meninges, and no trace of any parasite was
found. There was a projection over the corre-
sponding part of the skull. Shortly before death
some rigidity of the right arm had been observed ;
with this exception no symptoms referable to the
cyst had been noticed.
Prescott Hewitt, in 1845, contributed a paper
to the Royal Medical and Chirurgical Society,
in which he discussed the subject with great
acumen, and related several cases. In accord-
ance with the views then prevalent, he held that
the thin investing membranes were derived from
the fibrin of the blood, and he made the in-
teresting observation that he had seen similar
membranes enclosing blood collections in the
pleura. Curiously enough, though he referred
28 SOME POINTS IN THE SURGERY
to cases in Abercrombie's work, he made no
mention of Bright's cases.
Prescott Hewitt also discussed the subject in
his article on " Injuries of the Head " in Holmes's
System of Surgery. Good illustrations of these
cysts are there given and reference made to a
particularly striking case published in full in
The Lancet., 1846, vol. i. p. 416. A boy aged
eight years received a blow on the head from
a cricket ball and shortly afterwards showed
symptoms of insanity. He had recurrent attacks
of insanity with intervals of health until his
death, fifteen years after the injury. The
symptoms in the last attack were headache,
vomiting, and drowsiness. At the autopsy a
large arachnoid cyst was found.
Bearing in mind that in almost all serious
head injuries blood is extravasated into the
arachnoid cavity, it may well be that in cer-
tain cases of intermittent headache, intermittent
paralysis,, or intermittent insanity subsequent to
head injury the pathological lesion present is
arachnoid hasmatocele ; a condition certainly
remediable by operation.
As I have mentioned successful cases of
removal of large arachnoid hasmatocele, I must
record one on which I did not operate and death
ensued. It is noteworthy that in these cases
OF THE CEREBRAL MEMBRANES 29
of arachnoid hemorrhage there is a rise of
temperature.
W. W., male, ast. 56, groom. Typhoid fever
three years ago. No history of syphilis. Was kicked
by a horse over the left eyebrow three months ago.
Wound sutured by Dr. Halsted, who stated that there
was no fracture of skull. Was said to be quite well
until six weeks ago, when it was noticed that his left arm
was weak and that he dragged his left leg when walking.
Complete paralysis of left arm and leg four days before
admission, followed in twenty-four hours by frequent
vomiting and unconsciousness. Temperature 101° on
morning of admission. On examination reaction to
external stimuli delayed, but would answer to his
name if frequently called. Speech slow and slurred.
Paralysis of left arm and leg. Occasional clonic con-
tractions of right arm. In the intervals the limb was
held stiff ; hand-grip feeble. Right leg unaffected.
Knee-jerks brisk on both sides. Ankle clonus on right
side. Well-marked Babinski's sign on both sides.
Pupils dilated, equal and active ; no ophthalmoscopic
changes detected. No trace of albumen or sugar in
urine. Constipation of four days' duration and in-
continence of urine. Scar over left eyebrow ; no
apparent injury to bone beneath. Temperature 99° ;
pulse 60. Condition remained unchanged. Alter-
nating drowsiness and lucid intervals. Troublesome
constipation relieved by calomel and house mixture.
Temperature ranged between 98.2° and 100° ; pulse
rate gradually increased, reaching 1 20 on sixth day.
Seventh day, temperature 104.4 > coma and death.
P.M. — Bones of skull uninjured. Large arachnoid
blood-cyst found flattening all convolutions of right
30 SOME POINTS IN THE SURGERY
hemisphere. This was definitely encapsuled and the
sac could be demonstrated apart from the dura.
Contents dark and fluid. Right lateral ventricle com-
pressed ; left distended, its posterior horn was about
the size of a golf ball. CEdema of lungs. Chronic
nephritis.
During the life of the patient in St. Thomas' the
symptoms did not appear to justify operation. The
man was fifty-six years of age and looked at least ten
years older. He was accustomed to take a good deal
of alcohol. Learning more of the history of the case
after death and reading the P.M. notes, it is easy to be
wise after the event. It is noteworthy that the scalp
wound was on the side opposite to the arachnoid
haemorrhage. I may say that 1 could not be sure
before the autopsy was performed that the case was not
one of ordinary vascular lesion, though the alternating
drowsiness and lucid interval were suggestive of sub-
dural haemorrhage.
Gushing has recently drawn attention to
surgical intervention for the intracranial haemor-
rhages of the new^-born. Cerebral palsies,
epilepsy, and other nervous disorders, which may
be a permanent life disablement, are often due
to these hemorrhages arising from trauma
during birth. The unsupported venules passing
from the brain of the infant to the longitudinal
sinus and Pacchionian bodies are easily broken,
and thus large blood extravasations occur in the
subdural and sub -arachnoid spaces. Gushing
says these extravasations are usually unilateral.
OF THE CEREBRAL MEMBRANES 31
and that they give rise to post-partum asphyxia-
tion, a bulging fontanelle without pulsation, con-
vulsions, unilateral palsy, a stabile pupil on the
side of the hasmorrhage, irregular respiration,
slowing of the pulse, a rise of temperature,
inability to take nourishment, and death.
Gushing gives the details of four cases on which
he operated ; two were successful. I have not
had the opportunity of operating on such cases, but
Cushing's paper will, I believe, be a stimulant to
much good work in this direction in the future.
Besides the large collections of blood in the
subdural cavity which run a somewhat acute
course, surgeons are familiar with the localised
collections of clear fluid found years after an
injury in this situation and which produce
mental disturbances, convulsions, and headache.
The following is an illustrative case : — A man
aged twenty-five was struck some years before
admission to St. Thomas' Hospital on the right
frontal region. Since the injury he had suffered
from headache, irritable temper, and convulsions.
On exploring the frontal region, a cyst of the
arachnoid was discovered, containing clear but
slightly yellow fluid. The headache was cured
by the operation, but months after the operation
he had a fit, and the epileptic condition has
occasionally recurred.
32 SOME POINTS IN THE SURGERY
Fig. i+.
Fig. i(
Fig. U.
Figs. 14, 15, 16. — Intracranial haemorrhage of the new-born. (Gushing.)
Fig. 14. — Photograph of 9-day old comatose female infant. Note extreme degree
of ocular proptosis and subjunctival haemorrhage and cedema. Forceps delivery ;
inability to suck ; tense fontanelle ; Cheyne-Stokes respiration, and gradual onset
of coma.
Fig. 15. — Lateral view to show size and position of one of the symmetrically-
placed osteoplastic flaps. Operation on right side ; much blood-clot irrigated away,
dura stitched under tension. To relieve tension same operation performed on left
side with removal of further clot and relief of tension, as shown by recession of
fontanelle.
Fig. 16. — Same patient. Photograph during sleep two months after operation.
Complete retrocession of the exophthalmos.
OF THE CEREBRAL MEMBRANES ^3
Mr. Godlee read a most instructive paper at
the Pathological Society in 1885, "On simple
fracture of the skull in infants followed by the
development of pulsating subcutaneous tumours."
Similar cases have been reported by Sir Thomas
Smith, Mr. Golding Bird, and others. The
Fig. 17. — Sketch of operation for arachnoid cyst at St. Thomas's Hospital.
pulsating mass may consist of blood and cerebro-
spinal fluid with or without brain matter. Mr.
Godlee's cases were aged five months and
eight months. One of them had been also
under the care of Sir Thomas Smith. Both
died of septic infection. In both cases the
injury was caused by a fall out of window,
in one of eight, and in the other of four-
teen feet. In one of the cases the brain
D
34 SOME POINTS IN THE SURGERY
cortex had been ruptured so as to open the
ventricles.
Mr. Godlee writes : " When a young child
receives a blow on the head the mischief is
almost all spent upon the part struck and that
lying immediately beneath it. The process
extends little, if at all, beyond a single bone ;
indeed no one of the common fractures of the
4~
\
^El
\
^^^
^^gk,
^n^
^^X^
Fig. i8. — Simple fracture of skull in an infant. (Godlee, 1884.)
Male, set. 5 months. Fell 8 feet on to head. Large, soft hasmatoma right side.
Slow increase in size, with impulse on coughing. Twitching of left face, arm, and
leg. Vomiting. Much improvement in 2 months. Child left hospital with
tumour protected by gutta-percha shield. Soon became ill, and was admitted into
St. Bartholomew's with meningitis. Death 24 hours later.
skull as we meet with them in an adult can take
place in its typical form in an infant, but, on the
other hand, there are forms of fracture special to
the young skull. There are fractures of the
infant's skull, formerly described by Mr. Syme,
which would have been undetected (the bone
after breaking the adjacent dura and severely
lacerating the brain having sprung back in
place) had not actual brain matter been found
in the wound, beneath the scalp, or in the pus
OF THE CEREBRAL MEMBRANES 35
(as I saw in one case) evacuated from the
suppurating hematoma, which formed over it."
The following case, which was under the
care of Dr. Bastian in 1902, is an example
of a large traumatic encephalocele occurring
later in childhood, and illustrates a method of
Fig. 19. — Simple fracture of skull in an infant. (Gocllee, 1884.)
Female, aet. 8 months. Fell 14 feet on to head. Large haematoma right parietal
region. Temp. 101°. Pulse 140. Left hemiplegia. Twitching movements of
right limbs. Tumour at first diminished, but then began to increase in size.
Pulsation noticed loth day. Occipital bedsore formed : sepsis, death. Autopsy,.^
The tumour communicated throueh damaged dura and cortex with ventricle.
treating hernia cerebri.
A boy aged four years
fell twenty-two feet out of window. In falling
it was thought he struck the left side of the
head against a projecting window ledge. He was
unconscious for four days. A large non-pulsating
tumour formed over the left parietal region.
Some three and a half weeks after he had received
36 SOME POINTS IN THE SURGERY
the injury he was brought to London and I saw
him with Dr. Bastian. He had right hemiplegia,
complete aphasia, and some paresis of the left
third nerve. The tumour was slowly increasing
in size. Operation was decided on. A large
Fig. 20. — Traumatic meningocele. (Golding Bird, Guy'i Hasp. Reports, 1889.)
Female, aged 7 months. Fell on floor 6 days before being brought to Hospital.
A small swelling appeared in right parietal region immediately after injury. On
admission there was a large, tense, pulsatory swelling over right side of head. The
swelling was aspirated, blood and cerebro-spinal fluid being removed. It completely-
disappeared in 3 weeks.
Bior other cases see Lucas, Guy's Hosp. Reports, 1876, 1878, 1881, 1884, and
Silcock, C/iem. Soc. Trans, vol. xxi.
scalp flap was thrown downwards, exposing a
mass of brain substance, which was protruding
through a fracture of the parietal bone. The
break of the parietal bone extended downwards
and forwards obliquely from near the middle of
the sagittal suture. The edges were so clean
that they might have been cut with a knife, and
OF THE CEREBRAL MEMBRANES i^j
were separated about one-third of an inch. The
fragment of parietal bone in front of the fracture
-^^IS
Fig. 21. — Fracture of right frontal bone in a new-born infant, fracture extending
into orbit. (Von Bergmann, after Bruns.)
was removed by disarticulation at the sagittal
and coronal sutures. A corresponding piece of
Fig. 22. — I. Traumatic meningocele before operation. (Dembowski, Saivicki' s
Essay in Chipault.) z. Same case after operation.
Male, aged i6 months. Three months before being seen fell on head. Tumour
appeared and grew rapidly, so as to occupy right half of skull. Operation. — Part of
frontal and most of parietal bone depressed and almost detached. The posterior part
of parietal displaced backwards and outwards. Through the gap in the. parietal
bone the hernia cerebri protruded. Bone replaced. Gap closed by periosteal flap.
Patient recovered.
bone behind the fracture was removed. It was
then seen that the hernial mass of cerebral tissue
protruded between the sharp edges of a rent in
38 SOME POINTS IN THE SURGERY
the dura corresponding in position and extent to
the fracture in the bone. The opening in the
dura was enlarged by incisions made at right
angles to the tear, to the size of the aperture
made in the skull. Pulsation in the extra-
cranial mass at once recommenced. No further
Fig. 23. — Diagram of fracture of skull in Dr. Bastian's case of traumatic
encephalocele.
The bone enclosed by the dotted lines and by the frontal and sagittal sutures was
removed at the operation.
nipping of the junction of brain and hernia could
then take place. The brain had been damaged
to the depth of an inch along the line of fracture.
The scalp flap was replaced. The patient made
a good recovery ; the hernia soon disappeared.
Two years later Dr. Saunders of Pembroke Dock
wrote to Dr. Bastian : " Speech gradually im-
proved and now almost perfect except for some
OF THE CEREBRAL MEMBRANES
39
slurring when excited. Power over left leg
almost completely restored, of arm only partially
— no use of hand."
Lumbar Puncture in Injury to Brain and in
Apoplexy.
This seems a fitting place to point out the
great value of lumbar puncture in traumatic
lacerations of the cerebral substance when the
patient passes into the stage of cerebral irrita-
tion. A jockey, twenty-one years of age, was
thrown from a horse. There was no fracture of
the skull, but he was unconscious for ten days.
The right arm was paralysed, and there was
left ophthalmoplegia. I saw the patient with
Dr. Ferrier. From unconsciousness he passed
into a state of restlessness, irritability, and sleep-
lessness. By lumbar puncture 2.\ to 3 oz. of
red-stained cerebro-spinal fluid was drawn off;
on each occasion quiet sleep was obtained after-
wards for four hours. The man made a good
recovery. The question arises whether in some
cases of ordinary apoplexy the pressure of the
clot and serum on the nervous centres might
not be relieved with advantage by lumbar
puncture. In extra-dural haemorrhage, from
injury to the meningeal artery or a venous sinus,
40 SOME POINTS IN THE SURGERY
the fluid withdrawn by lumbar puncture is clear,
while in cerebral laceration or subdural haemor-
rhage it is blood-stained.
Pathology of Infection.
Infective processes may extend from a focus
of disease outside the skull to the interior of the
skull by —
1. The disease affecting the bone and a visible
track of bone disease forming a way of com-
munication.
2. Extending through a pre-formed channel,
such as a foramen or canal for the passage of
vessel or nerve.
3. Making its way through a congenital
defect in the ossification of the bone.
4. Extending along one of the processes of
dura mater, which in certain situations dip into
the bone.
5. Entering the circulation.
In some injuries infective material is intro-
duced directly by the injury into the interior
of the skull, a " stab culture " being in fact
made, and the natural resistance to penetration
being directly and abruptly broken down. This
is the sole difference in the pathology of the
intra-cranial complications of injury and disease.
OF THE CEREBRAL MEMBRANES 41
The infective process more or less rapidly
spreads within the skull from the spot where
the dura has been brought into contact with
infective material.
Extra-Dura! Suppuration.
At the spot where it has come into contact
with the pus the dura becomes inflamed and
extra-dural suppuration occurs.
This is the first stage of intra -cranial
infection. The resistance of the dura mater to
the further progress of the infection may be
great and prolonged. The effects are then
limited to the formation of a more or less
considerable localised extra-dural abscess. Or,
the dura may be softened and perforated forth-
with, and only a few drops of pus may collect
external to it.
The following case well illustrates the re-
sistance of the dura : —
A man was admitted to hospital on February
2nd with ear disease, which had already
extended beyond the limits of the temporal
bone. This was clearly shown by the fact that,
on irrigation of the ear until it was quite free
from pus, the pus rapidly re-filled the entire
auditory canal and overflowed into the concha.
The mastoid operation was done on March 12th.
42 SOME POINTS IN THE SURGERY
The following day a fistulous track was noticed.
This was enlarged with a sharp spoon. Recur-
rence of symptoms took place. On April iith
a free opening was made by chiselling away
sufficient bone, thus freely opening the extra-
dural abscess. From that time recovery was
uninterrupted (Bergmann). Pus must have
been in contact w4th the dura for at least nine
weeks (probably longer), but no perforation of
the dura took place.
At the post-mortem examination of a man
who- had died from acute meningitis within
forty-eight hours of the onset of illness, the
temporal bones, while the dura was still in
place, looked normal, but on removing the dura
the roof of the left tympanum looked a little
darker than that of the right. It was not
perforated nor carious, but a tiny thrombosed
vein was seen to issue from it. On breaking
through the tegmen the tympanum was seen to
be filled with a solid mass of granulation tissue,
which could be picked out all in one piece with
forceps. The long process of the incus was
necrotic. The tympanic membrane appeared
as if about to slough. There had been no
otorrhcea during life.
It is easy to understand how vascular infec-
tion could follow from such a condition.
OF THE CEREBRAL MEMBRANES 43
When the arachnoid is traversed the infection
reaches the sub - arachnoid and the pia, and
either a locaHsed or a diffused inflammation
resuks. Why the inflammation should in one
case be Hmited to a small or even a minute area
and in another should spread rapidly over the
whole surface is not difficult to understand.
The answer is that it depends on the nature
and virulence of the infection, just as a local
infection of the hand may end in a local abscess
or start a cellulitis which spreads in twenty-four
hours over the whole limb. The sub-arachnoid
tissue may then, like the areolar tissue of the
arm, be involved in either a local infection or in
a rapidly spreading cellulitis.
Infection of Arachnoid and Pia Mater.
It has long been known that effusion of
serum is one of the first effects of infective
irritation of the pleura, the peritoneum, the
joints, and the cellular tissue, but until the
publication of Quincke's papers on lumbar
puncture in 1891, and on meningitis serosa in
1893, it was scarcely appreciated that the
phenomena within the skull were just the
same, and the term meningitis was not con-
sidered applicable to any case in which purulent
44 SOME POINTS IN THE SURGERY
or at least sero - purulent effusion was not
obviously present within the meninges.
Quite early, even before meningeal were
distinguished from cerebral lesions, cases had
been observed and recorded in which no gross
Fig. 24. — Lumbar puncture. (Chipault.)
A. Method of Quincke. B. Method of Marfan. C. Method of Chipault.
The simplest plan seems to be to puncture between the 4th and 5th lumbar
vertebrae. The space between these vertebras corresponds to the highest part of
the iliac crests. Chipault, however, maintains that the lumbo-sacral space is prefer-
able since it is the largest, is surrounded by good landmarks, and is opposite the
terminal enlargement of the dural sheath.
intra-cranial lesion was found after death, though
the symptoms had seemed to point conclusively
to its presence. That great pioneer of cerebral
pathology, Thomas Willis, 1645, in relating
such a case, wrote : " Wherefore in this case no
other explanation seems possible but that the
vital spirits within the brain were put to
flight, or, so to speak, extinguished by particles
OF THE CEREBRAL MEMBRANES 45
of a malignant or narcotic or otherwise noxious
nature, so that the movement of the heart,
like the main - spring of a clock, being
arrested, all other functions, deprived of their
source of energy, immediately and absolutely
ceased."
Even now suppurative meningitis is looked
Fig. 25. — Lumbar puncture. (TufRer.)
A line joining the highest part of the iliac crests bisects , the space between the
4th and 5th lumbar vertebrae. This is the best guide in lumbar puncture. A fine
hollow needle, 7 cm. long, is required.
upon as a mortal disease, and some special
explanation has been sought of the recovery
of some patients presenting apparently un-
equivocal evidence of this lesion, and of the
absence of any appreciable lesion after death in
other cases with quite similar symptoms ; after
the vague terms pseudo-meningitis and menin-
gism had been used to designate such cases,
meningitis serosa was welcomed as a new fact
46 SOME POINTS IN THE SURGERY
in morbid anatomy affording an explanation of
these clinical phenomena.
Even while still without the dura a focus
of infection may determine an excess of fluid
within the skull, just as disease of a rib may
excite serous effusion in the pleura, or disease of
the tibia may bring about an effusion in the
knee-joint.
I have had many opportunities of observing
that clear fluid collects in the subdural cavity
when the dura becomes inflamed by the presence
external to it of pus. This is what we should
expect. Elsewhere, e.g. in the areolar tissue of
a limb, an inflammatory focus is always sur-
rounded by a zone of tissue tense and sodden
wdth serum, and, indeed, before the pus becomes
visible the site of the coming abscess is the site
of serous effusion or oedema. The same sequence
of events occurs in the cerebral meninges. In
the subdural space, which is not divided into
compartments, a pond of fluid will form, while
in the sub-arachnoid space of the cortex the
tissue, under normal circumstances being tra-
versed by countless rivulets of fluid (like marshy
ground), will become cedematous and swollen.
The following cases show the symptoms pro-
duced by meningeal effusion and the beneficial
effect of lumbar puncture. Probably in some
OF THE CEREBRAL MEMBRANES 47
cases the removal of fluid under pressure from
the intra-dural spaces will prevent the occurrence
of suppurative meningitis : — -
Case I. — J. C, aet. 19, female. — Admitted with R.
chronic otorrhoea and large mass of breaking-down
glands on the right side of the neck.
The radical mastoid operation was done, and all the
Fig. 26. — Sub-arachnoid space between the convohitions. (Key and Retzius.)
The sub-arachnoid space is here broken up into a number of channels, through
which the cerebro-spinal fluid finds its way. At each systole the fluid in the
ventricles is pumped into the spinal theca and into the great cisterns at the base of
the brain. It escapes from the spinal theca along the sheaths of the nerves, and
from the cisterna it passes upwards in the sub-arachnoid rivulets between the con-
volutions to reach the Pacchionian bodies and the superior longitudinal sinus.
affected
glands
in the neck were removed. The
glandular disease was tubercular.
The temperature for a few days was normal and
the pulse quick. The condition of the patient then
changed. The temperature rose, the pulse became
slower, sickness occurred, and she lay in bed in an
apathetic state, with eyes closed and mouth open.
Lumbar puncture was done, and with the withdrawal
48 SOME POINTS IN THE SURGERY
of 2 oz. of fluid all the symptoms disappeared. A
few days later the whole group of serious symptoms
returned, and were again relieved by lumbar puncture.
In another week she was again in a serious condition,
and, in addition to the other signs, there was now loss
of the sense of smell and commencing optic neuritis.
She was given chloroform, and an incision was made in
the dura over the tegmen tympani, which had been
removed at the first operation. This incision gave exit
to pus and gas from a localised abscess in the arachnoid
cavity. The patient made a good recovery.
Case 2. — A boy, aged twelve, at school, had a cold
on a certain Friday ; on Saturday and Sunday he com-
plained of pain in both ears. On Monday evening I
saw him. He was drowsy, temperature 104°, there
was oedema over the left mastoid, both tympanic mem-
branes were bulging. There was no discharge from
either side.
The same evening the right drum was incised, and
the operation for acute mastoid suppuration was done
on the left side. The lateral sinus was exposed in this
operation for i inch, part of which was of a pink colour
and inflamed.
The next morning patient was little if at all better,
and during the afternoon he was drowsy, complained of
headache, was restless and was sick. The temperature
was 102°, the pulse came down to 80, the pupils were
somewhat dilated and reacted slowly, tenderness was
manifest over the right mastoid, and the optic discs
were pinker than normal. The same evening an
operation was performed on the right mastoid of an
exactly similar character to that which had been carried
out on the left side ; every cell of the pneumatic
mastoid was full of pus, and the dura over the lateral
OF THE CEREBRAL MEMBRANES 49
sinus and beyond was red. Lumbar puncture was now
done, and 2 oz. of fluid under pressure were withdrawn.
The next morning there was no headache, no sickness,
no drowsiness, and the pupils reacted well. Convales-
cence was rapid, and on both sides practically perfect
hearing was regained.
Elusion in the pleura or peritoneum gives
Fig. 27. — sketch of complete mastoid operation.
In some acute cases tlie dura when exposed is found of a bright red colour. In
the figure the shaded areas over the antrum and attic, and over the sigmoid sinus,
indicate the usual sites of inflammation of the dura. (The complete mastoid opera-
tion is only very rarely required in acute cases ; the figure of the complete mastoid
operation is used because it shows clearly the region of the tegmen.) Meningitis
serosa may be induced by the inflamed dura, and can be relieved by lumbar puncture.
rise to physical signs by which its presence can
be detected quite independently of any symptoms
it may cause. Within the skull we are almost
entirely dependent upon symptoms for our dia-
gnosis, and it may be helpful to consider what was
accomplished and what was missed when the
diagnosis of diseases of the chest was unassisted
so SOME POINTS IN THE SURGERY
by the means of physical examination now
available.
Of late years our diagnosis of diseases of the
brain and meninges has been much assisted by
the practice of lumbar puncture. This gives us
certain and valuable information respecting the
nature of the fluid in the meningeal spaces, but
does not afford equally certain evidence as to
its amount and distribution. It should not be
forgotten that there is no direct gross com-
munication between the subdural and the sub-
arachnoid space ; the fluid obtained by lumbar
puncture may be derived from the one or from
the other, and we cannot tell from which.
In the skull, as elsewhere, the disease may be
arrested in the serous stage, or other inflamma-
tory lesions may arise.
Inflammation of the pia mater is neither
clinically nor anatomically distinguishable from
inflammation of the arachnoid, but either the
subdural or the sub-arachnoid space may be
the exclusive or the chief seat of the inflam-
matory exudation, a fact not without significance
in the treatment.
Diffuse suppuration in the subdural cavity is
uncommon except as the result of direct infec-
tion by injury, but I have seen it occur in in-
fluenza.
i
OF THE CEREBRAL MEMBRANES 51
Certain varieties of pus seem to have but
little tendency to perforate serous membranes
(such as the arachnoid or peritoneum) and but
little irritant effect upon them. The pus may
be spread out in a sheet of greater or less thick-
Fig. 28.
Fig. 29.
Fig. 28. — Arrangement of membranes around spinal cord. (Testut.)
The wide dark area is the subdural space. The light area around the cord is the
sub-arachnoid space. In the spinal canal the subdural is normally an actual space ;
in the cranial cavity it is a potential space.
Fig. 29." — Arrangement of arachnoid in the region of the cauda equina. (Charpy.)
In lumbar puncture the sub-arachnoid cavity is usually tapped. The fluid, how-
ever, in meningitis serosa may occupy the subdural space. The arachnoid will then
recede from the dura, these membranes being separated by an interval wider than
normal. Thus in some cases fluid may be withdrawn by the needle from the
subdural space.
ness over a certain limited area of the visceral
arachnoid, though there may be no visible
adhesions present which have checked its
spread.
In a v^oman, age forty-nine years, the subject
of chronic otorrhoea, who died after three weeks'
acute illness, a thick layer of yellow pus covered
52 SOME POINTS IN THE SURGERY
the visceral arachnoid exactly over the left frontal
and parietal lobes.
This is quite comparable to what not unfre-
quently occurs in the peritoneum and pleura.
It sometimes happens that in peritonitis the
exudation is apparently limited to a certain area,
though there are no adhesions present, and that
when the pus is wiped off the membrane under-
neath it looks unaltered.
The same appearance is sometimes noticed
in pleurisy with pneumonia.
When pus slowly makes its way to a serous
membrane adhesion of the two layers takes
place, and if the infection proceeds further it
traverses both layers without causing general
infection of the cavity. In the pleura and peri-
toneum the serous surfaces are kept in constant
lateral movement, and infective material is
rubbed over a considerable area before adhesions
can take place.
In the arachnoid the mechanical conditions
are different, there being no appreciable lateral
movement. The two layers therefore can, and
commonly do, become adherent before any con-
siderable area is affected, hence any collection of
pus between dura and pia is commonly quite
small in amount.
When the infection has traversed both layers
OF THE CEREBRAL MEMBRANES 53
of the arachnoid the sub-arachnoid space and
the pia are reached ; either a locaHsed or a dif-
fused inflammation may result here, or, forming
a mere track through the pia, the infection may-
pass on into the cerebral substance.
Varieties of Meningitis.
All intra-cranial affections, accompanied by
delirium, were formerly confounded together
under the name " phrenitis or phrenzy," and we
doubtless now include under the term meningitis
many affections which though attended in their
terminal stages by inflammation of the meninges
will, as our knowledge of cerebral surgery and
pathology advances, nevertheless be shown to be
quite distinct diseases, exactly as abdominal surgery
has shown us that diffuse suppurative peritonitis
is but a terminal stage in several distinct affec-
tions, most of which can be recognised and
arrested before that dangerous stage is reached.
For the present the surgeon classifies menin-
gitis as tubercular and non-tubercular; and recog-
nises that in each variety the pathological effusion
may be serous or suppurative, localised or diffused.
The anatomical distinction between tuber-
cular and non- tubercular meningitis is quite
clear, and the diagnosis can, moreover, be
usually made clinically. The various forms of
54 SOME POINTS IN THE SURGERY
non- tubercular meningeal affection cannot be
distinguished without bacteriological examina-
tion, though some points of difference both in
the symptoms observed and in the lesions found
have been noticed. Epidemic cerebro-spinal
meningitis and the posterior basal meningitis of
children, which are possibly the same disease,
are the two forms best differentiated.
Sympto?ns and Diagnosis.
There is no one pathognomonic symptom of
meningitis. The symptoms which arise are not
the direct result of the meningeal lesion, but are
largely due to the influence exercised by the in-
flamed meninges on the brain-substance beneath,
the symptomatology being, as the French writers
express it, a borrowed symptomatology.
Until quite recently we had to depend for
diagnosis upon symptoms alone, but within the
last few years the practice of lumbar puncture
has given us a valuable though indirect means
of physical examination.
Though most, if not all, of the symptoms
met with in cases of meningitis are also met
with under other conditions, yet clinical experi-
ence has taught us that a particular grouping of
certain symptoms is usually associated with
manifest meningeal lesions.
OF THE CEREBRAL MEMBRANES S5
In seeking to define the relation of symptoms
to lesions, and to apportion to each symptom its
exact diagnostic significance, we meet, as an
initial difficulty, with the fact that on the one
hand the symptoms are sometimes met with
without demonstrable meningeal lesion, and on
the other hand that gross meningeal lesions are
sometimes found post-mortem which had been
quite unsuspected during life.
Our present knowledge seems to show that
the symptoms most directly referable to the
meningeal inflammation are the three symptoms,
headache, vomiting, and constipation.
These are regarded as the cardinal symptoms
of meningitis ; the headache is severe and per-
sistent, the vomiting apparently purposeless and
not accompanied by nausea, and the constipa-
tion obstinate, resisting purgatives, and neither
accompanied by abdominal distension nor asso-
ciated with abdominal pain.
These three symptoms appear to depend
mainly upon intra-cranial effxision, whereby the
pressure relations are altered and the normal
power of adjustment of the intra-cranial tension
impaired, but in some degree also upon absorp-
tion of toxins.
Tension of fibrous tissues gives rise to pain.
Incision of the dura is painful. The headache
56 SOME POINTS IN THE SURGERY
of meningitis is comparable to the eyeache of
glaucoma ; both are due to tension of a fibrous
envelope enclosing a nervous tissue.
With these three cardinal symptoms are
associated two other groups of symptoms : —
A. Symptoms, such as fever and impaired
nutrition, resulting from general infection, and
depending more upon the variety of the infec-
tion than upon the distribution or degree of the
meningeal lesions.
B. Symptoms which are the clinical expres-
sion, not of the meningeal lesions, but of the
irritation of the subjacent cortex. These vary
with the nature, degree, and distribution of the
meningeal lesions, and with the cortical irrita-
bility of the individual.
Most of the symptoms met with in cases of
meningitis belong to this group. They are —
1. Psychic symptoms. — Irritability. Change
of disposition.
2. Motor symptoms. — Convulsions. Kernig's
sign. Exaggeration of reflexes.
3. Sensory symptoms. — Photophobia. Hyper-
esthesia.
4. Sympathetic vaso-motor disturbances. — Tache
cerebrale.
5. Finally symptoms due to exhaustion and death
of ?7erve ceils. — Paralyses. Anesthesia. Coma.
OF THE CEREBRAL MEMBRANES c^j
This group of symptoms being, as I have
already said, the clinical expression of irritation
of the cerebral cortex, it is easy to understand
that meningitis is by no means the only condition
capable of so affecting the cerebral cortex as to
give rise to them.
An actual lesion of the brain substance, the
absorption of toxic substances circulating in the
blood, and that still unexplained disturbance of
innervation known as hysteria may all give rise
to symptoms more or less closely resembling
those associated with meningitis. An absent
knee-jerk, a Babinski reflex, or early changes in
the optic disc w^ould be pathognomonic of an
intra-cranial inflammation in a case in which the
delirium and fever might have led to the sus-
picion of typhoid fever.
The diagnosis between these various con-
ditions is sometimes difficult, and occasion-
ally baffles even an attentive and experienced
observer.
Examination of the cerebro-spinal fluid ob-
tained by lumbar puncture affords information
as to —
1. The intra-dural pressure.
2. The chemical composition of the fluid.
3. Certain physical properties, such as the
freezing point.
58 SOME POINTS IN THE SURGERY
4. The cells contained therein.
5. The bacteriology.
6. The permeability of the meninges to
chemical substances introduced into the blood.
Of these the cytological examination is, at
present at all events, the most important.
Normally, the cerebro- spinal fluid contains
few or no cellular elements, but in inflammation
of the meninges the cellular elements are abun-
dant ; either leucocytes or poly-nuclear plasma
cells may predominate. The general indications
are that leucocytosis points to a slow or subsiding
inflammatory process, and abundance of poly-
nuclear cells to an acute, active, and intense
inflammation.
Systematic examination of the cerebro-spinal
fluid obtained by lumbar puncture in a series of
cases of acute diseases, whether symptoms of
meningitis were present or not, has shown
that —
1. Modifications of the cerebro-spinal fluid
and symptoms of meningitis may be present
together.
2. There may be symptoms of meningitis
without modification of the cerebro-spinal fluid ;
and
3. There may be modification of the cerebro-
spinal fluid without symptoms of meningitis.
OF THE CEREBRAL MEMBRANES 59
Therefore it seems that there is no necessary
and constant correlation between the symptoms
commonly accepted as indicating meningitis,
the lesions present, and the condition of the
cerebro-spinal fluid.
Our knowledge of the pathological physio-
logy of the symptoms is not yet sufficiently com-
plete to enable us to satisfactorily explain these
apparent discrepancies.
The diagnosis is then in most instances still
a matter of ordinary clinical observation and
judgment ; we have to determine whether the
patient's symptoms are due to meningitis or to
some other condition, and if we decide upon
meningitis, what is its variety and extent.
The conditions most frequently giving rise
to symptoms closely resembling meningitis are
hysteria, organic disease of the brain, and the
meningeal irritation occurring in the course of
certain acute specific diseases, notably pneumonia
and enteric fever.
Hysteria sometimes finds expression in symp-
toms having some resemblance to those of
meningitis, but a shrewd observer is not often
deceived thereby ; the disease indeed assumes
the mask of meningitis, but it is a mask at once
incomplete and exaggerated, some symptoms
being wanting, others caricatured. Other signs
6o SOME POINTS IN THE SURGERY
of hysteria are present, and the general condition
of the patient does not correspond to the gravity
of the symptoms.
It must never be forgotten that the neurotic
temperament affords no protection against organic
disease, and that the two conditions may co-exist.
The question of diagnosis between meningitis
and organic disease of the brain itself chiefly
arises when localisation symptoms are present.
Though bearing a general resemblance to those
of brain disease, these symptoms when due to
meningitis are usually to be distinguished by being
transient, irregular, and variable in their onset, by
the outlined rather than complete, the less pure
and more diffused character of their clinical ex-
pression, and by their acute or sub-acute evolution.
The meningeal symptoms due to acute specific
diseases very closely resemble those of suppurative
meningitis, but attention to the history and the
evolution of the disease usually soon enables the
diagnosis to be made. In such cases the sugges-
tion has been made, and seems probable, that the
symptoms are due to irritation of the brain by
the specific toxins of the disease.
We are usually able to diagnose clinically (i)
tuberculous meningitis, (2) non-tuberculous acute
meningitis, (3) the posterior basal meningitis of
infants.
OF THE CEREBRAL MEMBRANES 6i
In tuberculous meningitis the onset is in-
sidious, and the evolution sub-acute rather than
acute ; a period of apparent remission divides the
disease into the three stages so well described
long years ago by Robert Whytt.
Non-tuberculous general suppurative menin-
gitis has an acute onset and rapid course.
The posterior basal meningitis of infants be-
gins as an acute disease, but is less rapid in its
course than general suppurative meningitis, and
retraction of the head is a very prominent sign.
Posterior basal meningitis is a disease of the
first year of life. Tubercular meningitis is most
common from the second to the seventh year
(Mery and Armand Delille, 1905). While optic
neuritis depends in some measure upon the site
of the primary meningeal lesions, it may be
affirmed to be, as a rule, a late sign in tuber-
culous meningitis and an early one in suppura-
tive meningitis. Tubercle of the choroid when
seen is pathognomonic of tuberculous meningitis.
All forms of meningitis, if unrelieved by art,
tend to cause death.
Recovery is, however, undoubtedly possible ;
it has been inferred (i) from post-mortem
evidence after death from other causes, (2) from
the fact of recovery after clinical symptoms of
meningitis, and, lastly, from the recovery of
62 SOME POINTS IN THE SURGERY
patients with a local suppurative disease and
marked symptoms of meningitis after an opera-
tion limited to the local disease.
We are, therefore, justified in saying that the
meninges are not destitute of recuperative power,
but, like the peritoneum, are quite capable of
dealing with a certain amount of infective
material, if the further supply is cut off.
Treatment.
Paracelsus (circa 1490- 1 541) held that
" Nature was sufficient for the cure of most
diseases ; art had only to interfere when the in-
ternal physician, the man himself, was tired or
incapable. Then some remedy had to be intro-
duced which should be antagonistic, not to
the disease in a physical sense, but to the
spiritual seed of the disease." These remedies
were termed " arcana."
Antitoxins, and substances that appear to raise
the resisting power of the individual to certain
infective processes, are remedies fulfilling in
some degree the ideal of Paracelsus ; but such
remedies have, for most diseases, still to be found.
By removing a focus of disease, or by giving
free exit to infective products, surgery — though
essentially a remedy " opposed to disease in a
OF THE CEREBRAL MEMBRANES 63
physical sense " — has afforded us the means of
arresting many infective diseases which other-
wise must destroy life ; and we must now con-
sider whether surgical intervention can help us in
treating meningitis, for we have no other remedy.
From this point of view we may divide cases
of meningitis into two great groups — (i) those
due to extension of a local infective process,
and (2) those due to a general infection carried
by the blood stream.
In the first group it may at once be said that
the main surgical indication is the removal of
the local disease, and this surely should have
been carried out before the meningitis had arisen.
The importance of effectively dealing with
temporal bone suppuration is now fairly well
known, and the operation for its relief has slowly
become appreciated, though retrograde papers
on the subject continue to appear ; but in this
country the radical treatment of frontal and
ethmoidal suppurative disease is not always
thoroughly carried out. Even acute cases are
sometimes left till the patient has developed
meningitis, while in chronic cases the danger of
the disease is not recognised, and it is therefore
apt to be left unremoved.
Chronic suppuration in the accessory cavities
of the nose is exactly comparable to temporal
64 SOME POINTS IN THE SURGERY
bone suppuration, and like it should be treated
strictly in accordance with the ordinary sur-
gical principles applicable to the treatment of
diseased bone wherever situated — namely, com-
plete ablation.
Acute frontal sinus suppuration, and especially
acute necrosis of the frontal bone, is, if possible,
even more dangerous to life than acute temporal
bone suppuration ; urgent symptoms rapidly
develop, and operation is imperative. I was
recently called in consultation to such a case, in
which the patient's life was saved by immediate
operation.
The intra-meatal aural specialist of a past
generation was content to flit helplessly about
his chosen canal in the manifest presence of
lethal complications. Is it or is it not true that
the intra-nasal specialist of the present day, with
some brilliant exceptions, may at times be un-
duly influenced by the traditions of his otological
kinsmen instead of following the teaching of
Killian and facing the operation for the com-
plete removal of the disease .?
Operation for the cure of frontal and ethmoidal
suppuration is now regarded in this country
much in the same way as was the mastoid opera-
tion twenty years ago ; hence the fatal frontal
sinus cases so surprisingly frankly reported from
OF THE CEREBRAL MEMBRANES 65
time to time in our medical journals, as if the
disease was inevitably mortal, and as if the lesson
Fig. 30. — The relation of the frontal sinuses to the frontal lobes. (Killian.)
The frontal sinus is opposite the base of the corresponding first or upper frontal
convolution. In a large sinus the temporal recess may extend as far as the second
or middle frontal convolution. An abscess of the brain arising from disease of the
frontal sinuses is, as a rule, located in the anterior inferior part of the superior
frontal gyrus.
Fig. 31. — The relation of the accessory sinuses to the base of the skull 5
viewed from the cranial cavity. (Killian.)
The frontal, ethmoidal, and sphenoidal sinuses are exposed. With the exception
of the posterior two-thirds of the sphenoidal sinuses, all the accessory sinuses abutting
on the cranial cavity lie in the region of the anterior cranial fossae.
that danger attends delay and imperfect operation
had yet to be learnt.
F
66 SOME POINTS IN THE SURGERY
When the opportunity for a preventive opera-
tion has gone by, and meningitis has resulted
from a local cranial lesion, the chances of recovery
are naturally much lessened, but even then surgery
is not helpless. Many cases are recorded in
which recovery has followed the removal of the
local disease by an operation not opening the
dura, even though symptoms of meningitis were
already present.
The following is an instance of such a
case : —
In April 1901 I saw with Mr. Tyrrell a boy,
aged nine years, who had just returned from
Paris.
There was a clear history of tubercle in his
family.
Three years previously tubercular glands had
been removed from both sides of his neck. A
slight watery discharge from the right ear had
been noticed a year before the operation on
the neck, and had continued without inter-
mission.
Six weeks before I saw the patient he had
complained of pain in the head on running.
During the two preceding weeks he had had
severe pain in the head at intervals, with vomit-
ing. Squint of the right eye had been noticed
for a week.
OF THE CEREBRAL MEMBRANES 67
When seen he complained of constant pain
in the head with exacerbations. The tempera-
c =
too (U
.2 -°
a o
I f*
ture was gg F. ; the tongue was furred. There
was a slight watery discharge from the right
68 SOME POINTS IN THE SURGERY
tympanum coming through a large perforation
in the anterior part of the membrane. The
OJ o
so
right external rectus was paralysed. No optic
neuritis.
OF THE CEREBRAL MEMBRANES 69
Complete mastoid operation forthwith. The
dura covering the tegmen and a considerable
area of the dura of the posterior fossa, in-
FiG. 34. — Result six weeks after the K.1I11.111 operation tor frontal sinus suppuration.
Miss D., age 27 years. When seen the right frontal sinus was obviously
enlarged ; it extended upwards on the forehead for some distance and outwards,
with diminishing vertical extent, as far as the external angular process. A streak of
pus could be seen in the middle meatus. The antrum of Highmore was translucent,
but the right frontal sinus was absolutely opaque to transmitted light.
Three years previously she had been struck in the right frontal region, and for
two years had had constant aching in that situation and discharge, usually watery
and without odour, from the right nostril.
Operation. — The usual vertical incision was made, with another running along the
orbital margin of the eyebrow instead of along the line of the hair, where it sub-
sequently causes an unsightly mark. The outer table of the skull was raised up
with the forehead flap (Durante's osteoplastic flap). The sinus was full of granula-
tion polypi and pus, and on displacing the tendon of the superior oblique and
removing the roof of the orbit, the same condition was found in the ethmoidal cells
and in the sphenoidal sinus. The disease was entirely ablated, and the various
cavities were thrown into one by removing the bony partitions between them 5 this
was swabbed out with chloride of zinc solution (40 grs. to i oz.). The middle
turbinated bone was removed. The skin edges were then accurately sutured, and
drainage provided for through the right nostril. Convalescence was rapid and
complete. The patient complained of diplopia for two weeks.
Even at Freiburg patients do not escape without a slight depression in the forehead
after the Killian operation by the master himself. To obviate this I made use of
Durante's osteoplastic flap. This, of course, cannot be employed unless the operator
can ensure complete eradication of the disease. Making the horizontal incision
below, instead of through the hair of the eyebrow is, I think, also a great improve-
ment. The cedema of the right upper eyelid had not quite subsided when the
photograph was taken. The vertical incision can just be seen in the full-sized
photograph. There is no flattening over the operated sinus.
eluding the
The mastoid.
sinus wall, was granulating.
except the outer shell, was
destroyed by granulation tissue, which was
found by Mr. Shattock to be tubercular. The
70 SOME POINTS IN THE SURGERY
granulating dura was painted with absolute
phenol.
The patient made a complete recovery. In a
week the headache had ceased, and in three and
a half months the sixth nerve had recovered its
functional activity.
This case also illustrates the futility of
removing tubercular glands of the neck and
leaving mastoid disease untouched.
In such cases there must always be some
doubt whether anything more than serous
effusion had occurred within the dura.
When cerebral symptoms persist after the
removal of local disease of the cranium the dura
should be opened by an extension of the local
operation, and further procedure guided by the
condition found.
We have now to consider what should be
done when meningitis has occurred otherwise
than as a complication of some local cranial
lesion.
Tuberculous Meningitis.
So fatal is this disease that even the bare
possibility of recovery without permanent damage
to the brain has been doubted.
It is true that certain cases have been reported
as recoveries, but of these some may well have
OF THE CEREBRAL MEMBRANES 71
been localised cerebral tubercle, and in others the
observer may have been deceived by a toxsemic
meningitis.
The results of opening the abdomen in tuber-
culous peritonitis have led to the hope that
something would be accomplished by opening
the skull in cases of tuberculous meningitis, but
the few efforts that have been made in that
direction have afforded but little encouragement.
Must we accept the results hitherto obtained
as final, and conclude that no benefit is to be
derived from intervention in these cases ? Before
accepting defeat we should consider whether the
measures hitherto adopted are those most likely
to prove successful.
In operating for tuberculous peritonitis we
neither remove the disease nor the source of
infection, and it is by no means clear in what
way the modification in the evolution of the
disease is brought about, but it certainly seems
that exposure of the disease and drainage of the
inflammatory exudation must be the main factors.
The operation is simple and easy of execution.
A problem of much greater complexity con-
fronts the surgeon who seeks to deal with
tuberculous meningitis in the same way. To
obtain direct access to the disease and to drain
the morbid exudation it would be necessary to
72 SOME POINTS IN THE SURGERY
expose and open the Sylvian lake, and also to tap
the ventricles, for the tubercular disease lies in
the sub-arachnoid space, mostly in the Sylvian
fissure, and in the choroid plexus of the ventricles.
Irrigation of the ventricles and sub - arachnoid
space would be equally necessary, and these
cavities cannot be irrigated the one from the other.
Chipault in 1895 suggested that instead of
Fig. 35. — Miliary tuberculosis of pia covering the convexity of the brain. (Lebert.)
merely opening the arachnoid, the Sylvian lake
on each side should be opened. Writing again in
1904 he says that though several surgeons have
accepted his views there is as yet no practical
confirmation of the value of the suggestion.
Some of the operations hitherto performed
have, however, been limited to opening the sub-
dural space ; consequently direct access to the
disease and direct drainage have not been obtained ;
OF THE CEREBRAL MEMBRANES ^'},
the sub-arachnoid space, where the disease lies,
being left untouched. This procedure is merely-
opening a neighbouring cavity : opening the
pleura could have little influence on disease in
the pericardium.
Until more complete operations have been
performed in an earlier stage of the disease we
cannot say whether tuberculous meningitis is
likely to be modified in the same favourable
manner by operation as is tuberculous peritonitis.
General Suppurative Meningitis.
The indications for treatment are to suppress
the source of infection, to give free exit to the
suppurative exudation and to combat the disease
with the appropriate anti-toxin.
Some remarkable and encouraging results of
surgical intervention in this desperate disease
have been already published. Kiimmel relates
the following case : —
A man, aged thirty -three years, fell, striking his
occiput ; for two days he felt pretty well, then had
gradually increasing headache, especially occipital, and
vertigo, together with tinnitus and deafness in the right
ear. There had been a watery discharge from the nose
the day after the accident. On the sixth day he was
admitted to hospital as the symptoms had increased in
severity. He was then still able to walk ; he complained
of frontal and occipital headache. No paralysis nor
74
SOME POINTS IN THE SURGERY
eye- changes were observed. There was right-sided
deafness, but no visible lesion of tympanic membrane,
Cerebro-spinal fluid was discharged through the nose.
On the third day after admission he became torpid, and
his temperature rose to 104 ; next day there was com-
plete unconsciousness, with marked rigidity of neck
and squint. Lumbar puncture let out 20 cc. of purulent
Fig. 36. — General suppurative meningitis. (Cruveilhier.)
In the original beautiful drawing greenish pus is seen everywhere beneath the
arachnoid ; in the sulci, and over the middle part of the upper surface of the
cerebellum.
The stream of fluid passing upwards from the cisternae at the base through the
sulci of the convexity to the Pacchionian bodies explains the rapidity with which
pus spreads over the convexity in cases of fulminating meningitis. To relieve this
condition drainage of the sub-arachnoid space is necessary.
fluid under pressure of 235 mm. Hg. Profoundly
unconscious all the day, the lumbar puncture gave no
relief; urine passed under him. Following day (fifth
after admission) apparently moribund.
Operation as a forlorn hope. Opening made in
the bone as large as a five-shilling piece on each side
of the middle line low down in occipital region. Dura
under pressure. Dura excised over whole extent of
OF THE CEREBRAL MEMBRANES 75
bone opening. Arachnoid deeply congested, only a
small quantity of sero-purulent fluid escaped. Large
plugs of gauze inserted in openings as deeply as possible
into the posterior fossa, skin flap sutured, after pro-
viding for drainage. The patient gradually improved,
and in six weeks was discharged well.
Hinsberg refers to this and other cases in a
paper published last year. It is probable that
in this case the sub-arachnoid space was opened,
but it is not clear from the description given that
this was done as a deliberate measure. Hinsberg
says that up to the present at least ten cases of
recovery from meningitis after drainage of the
sub-arachnoid space are known, and five in which
marked improvement occurred.
Suppurative meningitis may, as we have seen,
chiefly or wholly aflfect either the subdural or
the sub-arachnoid cavity. When on opening
the subdural space we meet with a sheet of pus
we have no ready means of ascertaining how far
it extends, and it is difficult or impossible to
remove the pus by irrigating from one opening
to another.
Continuous irrigation is conceivable, but
cleansing by wiping is impossible, unless bone is
removed to the full extent of the pus sheet.
In general suppurative meningitis the opera-
tion aflfording the best chance of success is one
76 SOME POINTS IN THE SURGERY
which provides a free bi-lateral opening, and
allows the escape of pus from the sub-arachnoid
space. It has been moreover rightly suggested
that the spinal theca should be opened in the
lumbar region so as to permit irrigation from
the cranial to the spinal cavity.
Posterior Basal Meningitis of Infants.
The main surgical indication is the relief of
the internal hydrocephalus, which is apt early
to arise from the effusion blocking the foramina
through which the cerebro-spinal fluid escapes
from the ventricles.
We have various methods for the surgical
treatment of hydrocephalus, and of these I have
had considerable experience at the Hospital for
Sick Children, Great Ormond Street.
I. The Parkin operation I carried out many
years ago in several cases under the care of Dr.
Lees and Sir Thomas Barlow. In this operation
an opening is made in the occipital bone, and
through it the pia-matral expansion over the
back of the fourth ventricle is broken through.
We found it a very severe operation in infants,
and it moreover fails if the Sylvian aqueduct is
blocked. These operations mostly occurred in
the Winter, and we kept the infants alive
OF THE CEREBRAL MEMBRANES ^-j
after operation by placing them in an incubator.
In only one case was the child cured, and
in this one the ventricles were tapped also
Fig. 37. — Posterior basal meningitis. (Lees and Barlow.)
Head retraction, marked opisthotonus, rigid extension of limbs. In some cases
there is no opisthotonus, and there is flexor spasm of limbs. The head retraction
is the characteristic sign. It is seldom so marked in tuberculous meningitis.
Child's age at onsst, 16 months. Ill 13 weeks. The 4th ventricle was dilated.
The iter and the foramen of Monro were obliterated. The hydrostatic system of
the brain and cord was partitioned by adhesions into four sections : the right lateral
ventricle, left lateral ventricle, 3rd ventricle, and 4th ventricle, and sub-arachnoid
space of cord.
The left ear contained semipurulent fluid.
through the anterior fontanelle. Unfortunately,
a few months afterwards the child was re-
admitted to the hospital with diphtheria and died.
78 SOME POINTS IN THE SURGERY
2. Successive tappings of the ventricles may
give some relief.
3. Lumbar puncture often fails to drain the
Lateral Venencle
Fig. 38. — Diagram of subdural drainage by an angular metal tube.
The tube is sutured to the dura. The second loose suture prevents the displace-
ment of the tube if the cortex sinks away from the dura. Occasionally the amount
of fluid will be in excess of that which can be absorbed by the Pacchionian bodies.
The internal hydrocephalus then becomes an external hydrocephalus, and the head
may continue to enlarge.
The tube employed is much smaller than that shown in the figure.
ventricles of hydrocephalic infants, as the
foramina of Majendie and Luschka may be
congenitally absent or blocked by antenatal
OF THE CEREBRAL MEMBRANES 79
menino:itis or adhesion of the cerebellum to
the medulla : the Sylvian aqueduct may also be
blocked.
4. Intra-diiral drainage^ suggested by Cheyne
and Sutherland, succeeds if the fluid is not
too rapidly secreted to be drained off by the
Pacchionian bodies, otherwise it only converts
an internal into an external hydrocephalus ; a
fact which I have several times observed.
The plan of drainage can be carried out through
the lateral angle of the anterior fontanelle, or
the descending cornu of the lateral ventricle on
the right side may be opened by the ingenious
method of Keen. A fine tube bent at a right
angle, made of gold and iridium, or of platinum,
should be used.
Cases of successful treatment of hydrocephalus
interna by intra-dural drainage : —
(a) Posterior Basal Meningitis and Hydrocephalus.
Male, aged three and a half, acute illness with
pyrexia, head retraction, and right otorrhoea, followed
by a stage of irritability, vomiting, rigidity of limbs, and
emaciation.
Six weeks after admission to Great Ormond Street,
intra-dural drainage was carried out by passing a number
of silk threads through a fine opening in the cortex.
Ten days later silk threads were replaced by a fine india-
8o SOME POINTS IN THE SURGERY
rubber tube. A fortnight" after second operation
child knew his mother and spoke to her. The tube
was left in situ for two months and then removed.
The child left the hospital well but quite deaf.
Seven years later (at age of ten and a half) child
happy and healthy at a deaf and dumb school,
making progress at the lip language. Like other
children, but perhaps more tendency to fall when
running about.
(b) Congenital Hydrocephalus.
Child, aged ten months, admitted to Great Ormond
Street in December 1903. The head had been
increasing in size for three or four months. The
circumferential measurement is 23 inches. The
eyeballs are depressed, and there is some lateral
nystagmus and occasional vomiting. The child is
emaciated.
January 1904. — A fine angular platinum tube was
passed through the cortex into the descending cornu of
the lateral ventricle on the right side.
June 1904. — Quite well ; beginning to talk. Mind,
sight, hearing, and speech normal.
January 1906. — Child quite well. Head looks
large ; measures 2 1 inches in circumference. It is
so heavy that the infant has much difficulty in
moving it.
5. The secretion of fluid may be lessened by
ligature of one or both common carotid arteries.
This can be safely done in hydrocephalic chil-
dren, in whom the blood-supply to the brain
OF THE CEREBRAL MEMBRANES 8i
stem is of much more relative importance than
that to the cerebral substance and the choroid
plexus.
Congenital hydrocephalus treated by ligation
of both common carotid arteries : —
George C, aged eleven months, was admitted to my
ward in the Hospital for Sick Children, Great Ormond
Street, on October 21st, 1905. The head had been
enlarging since the age of three months. Circum-
ference now 23I- inches, intermeatal measurement 17
inches. Eyeballs depressed, lateral nystagmus, tempera-
ture 90° to 100°, occasional vomiting, emaciation. An-
terior fontanelle very prominent and tense.
October 2 8//z. — Right common carotid tied. One
ounce of cerebro-spinal fluid drawn off through the
lateral angle of the anterior fontanelle by a fine trocar
and cannula to relieve tension.
November \th. — Left common carotid tied. The
pulse became very weak, but the respiration con-
tinued. The child gradually recovered, but I thought
it well to withdraw a little cerebro-spinal fluid from
the anterior fontanelle early in December. About
the middle of January the child left the hospital
apparently quite well, and with no abnormal pressure
of the fontanelle.
I have treated another case of congenital
hydrocephalus in the same way. The child was
under the care of Dr. James Collier of the
National Hospital, Queen Square. This patient,
82 SOME POINTS IN THE SURGERY
however, died, but I
ligation of the carotids
Fig. 39. — Congenital hydrocephalus in
an infant of 6 months. (D. Schwartz,
Cackovic's article in CAipault.)
Child aged 16 months. A litre and
a half of- cerebro-spinal fluid was with-
drawn through the anterior fontanelle.
Head reduced in size, and eyes more freely
moved. Ultimate result not known.
do not think that the
was the cause of death —
one of the wounds was
exposed to the air and
became septic and this
was followed by high
temperatures.
Dr. Hildesheim has
recently published an
admirable paper on pos-
terior basal meningitis.
He refers to the occur-
rence of the disease after
the first and second years
of life, and points out that many cases of appar-
ently acute hydrocephalus in adults and older
children are really exacerbations of a chronic
condition.
About fifteen years ago a man, twenty -six
years of age, came to see me from Yorkshire.
Both nostrils were full of mucous polypi. A mass
of these growths projected from the posterior
nares on to the soft palate. The patient answered
my questions clearly, but the father, a farmer, said
that his son was not mentally capable of super-
vising any work on the farm. The polypi were
removed by Banks' method. The operation was
easy — one application of the forceps on each
OF THE CEREBRAL MEMBRANES 83
side brought away the polypus mass. The
bleeding was not excessive. All went well till
the third day, when the temperature rose to
103° F. ; vomiting
and delirium set in,
and three days later
death ensued. With
some difficulty an
autopsy was ob-
tained. All that we
found was chronic
hydrocephalus. The
foramina in the roof
Fig. 40. — Congenital hydrocephalus treated by
qJ the fourth Ven— ligation of both common carotid arteries.
tricle were blocked by old basal meningitis. There
was no recent meningitis and no injury to the
roof of the nasal cavity. I then saw the parents
and asked them if they could recollect any illness
their son had during the first year of life. To
my surprise and interest they told me that their
son had had a severe illness before he was a year
old, lasting some months. The head increased
in size, and was retracted so as to touch the
back — vomiting was frequent and his life was
despaired of. Gradually the symptoms had
abated, but had left considerable impairment of
mental power during school time and after-life.
84 SOME POINTS IN THE SURGERY
Conclusion.
Our predecessors, in dealing with acute head
infections, applied vigorously those measures
which they believed to be of service in treating
similar affections in other parts of the body.
We have abandoned the venesection and
severe purgation employed by our forefathers
as remedies for acute infective disease. In parts
of the body other than the cranium we have
replaced them by appropriate surgical measures,
but in the treatment of intra-cranial infections
we have replaced the vigorous if inappropriate
measures of our predecessors by an equally
inappropriate inertia.
Hinsberg, in the concluding paragraph of his
paper on the subject, says : — " It can no longer
be doubted that in some cases of suppurative
meningitis recovery may be brought about by
active intervention. We are as yet quite unable
to say how large a fraction this may prove to
be. Personally I am not sanguine that it will
be a large one, for the difficulties I have men-
tioned as attending the diagnosis and localisation
and the dangers of the after-treatment are still
so great that a quite special concatenation of
favourable circumstances is necessary for them
all to be overcome."
Twenty -five years ago acute abdominal in-
OF THE CEREBRAL MEMBRANES 85
fections from the appendix, the bile ducts, and
the Fallopian tubes, ruptured tubal gestation,
and intestinal obstruction were almost as fatal
as the acute infections of the meninges ; to-day
these abdominal affections are treated surgically
with considerable success, not only by those of
exceptional ability and opportunities, but is a
matter of ordinary practice.
I am convinced that our treatment of intra-
cranial infection has been too long encrusted
in conventionality, and that " we are no longer
justified in regarding such cases as hopelessly
lost, and in remaining with folded hands, the
rather must we attempt to save them by doing
the utmost within our power."
REFERENCES. LECTURE I.
Lettsom. Biographical notes, chiefly obtained from Life and Letters
of Dr. Lettsom, by T. J. Pettigrew.
Key and Retzius. Studien in der Anatomic des Nerven-Systems
und des Bindegewebes. Stockholm, 1875.
Charpy. Traite d'Anatomie Humaine. Poirier and Charpy.
Leonard Hill. The Physiology and Pathology of the Cerebral
Circulation. London, 1896.
Lees and Barlow. Simple Meningitis of Children, In Allbutt's
System of Medicine, vol. vii.
Imbert. In Traite elementaire de Physique medicale. Wundt-
Monoyer. Second French edition.
Watson, Sir Thos. Lectures on the Principles and Practice ot
Physic. London, 1871.
MoTT. British Medical Journal, 1904.
Aorta of Turtle. Specimen No. 863^, Physiological Series, Royal
College of Surgeons' Museum.
86 THE CEREBRAL MEMBRANES
Taylor and Ballance. Removal of Arachnoid Cyst. Lancet,
August 29th, 1903. •
Richard Bright. Reports of Medical Cases.
BiRouLA. Societe de Psychiatrie de S. Petersbourg. Reported in
Revue Neurologique, 1897, p. 206.
Prescott Hewitt. In Holmes' System of Surgery, vol. i., third
edition, 1893, and Med.-Chir. Trans, vol. xxviii.
Abercrombie. Pathological and Practical Researches on Diseases
of the Brain and Spinal Cord, 1828.
CusHiNG. American Journal of Medical Sciences, October
1905-
GoDLEE. Pathological Society's Transactions, vol. xxxvi, 1885.
Sir Thos. Smith. St. Bartholomew's Hospital Reports, 1884..
GoLDiNG Bird. Guy's Hospital Reports, 1889.
Ballance. In Chipault. L'Etat actuel de la Chirurgie Nerveuse,
vol. iii. 1903.
Bergmann. Die Chirurgische Behandlung von Hirnkrankheiten.
Quincke. Verhand. des X-° Congress fiir innere Medizin, 1891, p.
322, and Volkmann's Klinische Vortrage. Neue Folge, No. d'] .
Willis, Thos. De Anima Brutorum. Part 2, p. 276.
Ernest Dupre. In Traite des Maladies de I'Enfance. Grancher-
Comby (symptoms of meningitis).
Georges Guinon. In Traite de Medecine. Charcot-Bouchard-
Brissaud (for information afforded by lumbar puncture).
Robert Whytt. Observations on the Dropsy of the Brain, 1768.
Mery and Armand Delille. In Traite des Maladies de I'Enfance.
Grancher-Comby.
Paracelsus. Ouoted from Dr. Payne's Article on the History of
Medicine in Encyclopaedia Britannica.
Chipault. Traite de Chirurgie operatoire du Systeme Nerveux
and I'Etat Actuel de la Chirurgie Nerveuse.
KiJMMEL. Archiv. fiir klinische Chirurgie, vol. Ixxvii. p. 930.
Hinsberg. Zeitschrift fiir Ohrenheilkulide, vol. xxxviii. p. 126,
and vol. 1. p. 261.
Parkin. The Lancet, 1893.
Cheyne and Sutherland. Clinical Society's Transactions, 1898.
Keen. Medical News, 1888.
Hildesheim. Dissertation of the Degree of M.D., Oxon. See also
Practitioner, 1905.
PuRVEs Stewart. The Clinical Significance of the Cerebro-Spinal
Fluid. Edin. Med. Journal, 1906.
LECTURE II
SOME POINTS IN THE SURGERY OF ABSCESS OF
THE BRAIN
Etiology — Morbid anatomy and pathology — Infection of brain
substance — Manner of development, form, and situation —
Clinical evolution — Symptoms and diagnosis — Complications
— Operative treatment of the varieties of abscess — Recent im-
provements in details — Concluding remarks.
It is now almost universally accepted that
suppuration does not occur without the inter-
vention of microbes ; various species of micro-
organisms have been found associated with
suppuration within the brain, and each of them
might be spoken of as a cause of cerebral
suppuration.
To the practising surgeon, however, the
general or local disease of which the cerebral
suppuration is a complication is the dominant
etiological factor. Not because the bacterio-
logical diagnosis is not of importance in treat-
ment, but because it is not usually available until
the clinical diagnosis has been put to the proof.
87
88 SOME POINTS IN THE SURGERY
With what diseases, then, is brain abscess
associated ?
1. Injuries to the head.
2. Local cranial suppurations.
3. Certain general infections.
4. Certain local diseases other than those of
the head.
Abscess of the brain complicating injuries
to the head is too well known to need any
exposition in this place ; I will only remark
that, except when the instrument causing the
injury has penetrated deeply into the brain sub-
stance, the abscess is in most cases really a local
meningeal suppuration with participation of the
adjacent brain cortex, a meningo-cortical abscess
rather than a brain abscess proper.
Less frequently injury leads to local chronic
disease of bone, from which a brain abscess may
subsequently arise. I have elsewhere spoken of
brain abscess secondary to local cranial suppura-
tion.
The general infective diseases most liable to
be complicated with abscess of the brain are (a)
pyaemia ; (^) tubercle ; (r) certain specific fevers,
such as influenza, enteric fever, or variola.
Little need be said of brain abscess secondary
to general pyaemia. The brain is one of the
less common localisations of pyemic abscess, and
OF ABSCESS OF THE BRAIN 89
general pyemia is happily a disease well on its
way towards becoming extinct.
It is of great interest that cases have been met
with of abscess of brain, apart from any other
macroscopic intra-cranial tubercular lesion, which
have yielded pure cultures of the tubercle bacillus.
Cases of brain abscess following, and appar-
ently caused by, the acute specific fevers, with-
FiG. 41. — Traumatic meningo-cortical abscess of brain. (Starr.)
The abscess was in the inferior parietal region, and was secondary to fracture of
the skull. The thick capsule of the abscess can be seen. The patient was an infant.
The injury was followed in two weeks by hemiplegia and hemianopsia.
In 22 cases of brain abscess observed at the Presbyterian Hospital, New York,
12 were due to trauma. Starr also relates 3 cases which recovered.
out any evidence of disease of the cranial bones
or anything to suggest pyaemia have been from
time to time reported ; for example. Dr. Bristowe
in 1 891 published two such cases (to which I
shall have again occasion to refer) following
influenza. These cases rarely come under a
surgeon's observation ; they present great diffi-
culties in diagnosis, and even when brain abscess
has been suspected there has usually been little
or nothing to show in which region or even
90 SOME POINTS IN THE SURGERY
on which side of the brain the abscess has
developed.
The local disease elsewhere than in the head
which is most liable to be complicated with
brain abscess is putrid inflammation or gangrene
of the lung. Brain abscess supervening upon
this condition has been observed and recorded
for at least fifty years. Though it is clear
enough that the infection is carried in the
blood-stream, no adequate explanation is as yet
forthcoming why it should be localised in the
brain.
In 1 90 1 Clay tor collected reports of 58 cases
of brain abscess secondary to disease of the lungs,
most of which occurred on the left side of the
brain. The particular form of lung disease was
in 20 cases bronchiectasis, in 10 empyema, in
9 purulent bronchitis, in 7 gangrene of lung,
in 5 tuberculous disease, in 3 abscess of lung, in
2 pneumonia, and in 2 gunshot wound of lung.
Stoll reports a case of abscess in left frontal
lobe, and a cavity in the apex of the right lung
2^ cm. in diameter. A similar case to that of
Stoll is reported in the Lyon Medica/e, 1904.
Blottche found pulmonary pigment in the
pus of certain brain abscesses.
OF ABSCESS OF THE BRAIN 91
Examples of Brain Abscess following Pulmonary Disease.
Case I (Cayley). — Male, aged nineteen years. — Severe
attack of pleurisy lasting eight weeks. Haemoptysis
during the attack and, in small quantities, at intervals
subsequently.
Three years afterwards. Headache, vomiting, tem-
porary loss of power in left arm and leg. Renewed
haemoptysis. Complained of some confusion of thought
but answered questions rationally though slowly. Con-
stipation, Dulness at left base with bronchial breath-
ing and bubbling crepitation. Five days after com-
mencement of head symptoms he had a fit with
clonic spasms affecting first the left leg, then the trunk,
and then the left arm ; there was no loss of conscious-
ness, and he attempted to control the movements with
right arm. Vomiting and headache increased. Pulse
44, temperature 96.6°. Edges of disc blurred. Died
five days later. At the autopsy two abscesses were
found in the brain. One in the centrum ovale of the
right hemisphere as large as an unshelled walnut. " It
gave off from its upper part a prolongation or loculus
which reached the surface in front of the superior
parietal lobule at the top of the ascending frontal con-
volution, the grey matter of which was partly destroyed
by it. Though in this region quite superficial the
abscess had not burst on to the surface of the brain.
This upper loculus communicated with the principal
cavity by an aperture the size of a crow-quill."
Bronchiectasis of left lung and enlarged bronchial
glands without evidence of tubercle. The diagnosis
during life had been tubercular tumour.
Case 1 (Pye-Smith). — Male, aged nineteen years. —
Empyasma treated by simple incision, August 16,
92 SOME POINTS IN THE SURGERY
1876. Irrigated with weak iodine solution. Wound
had healed and lung expanded by October 5, On
October 6, vomiting, headache, and delirium. Tem-
perature 1 01. 8. Left hemiplegia. Died three days
later. Autopsy. Residual abscess between lobes of
lung. Purulent meningitis, pus beneath arachnoid.
Two abscesses in right cerebral hemisphere each as
large as a marble, the one involving the gyrus forni-
catus, and the back of the optic thalamus, and the
other situated in front of the corpus striatum. Both
abscesses had burst into the ventricles.
Case 3 (Rudolph Meyer, 1864). — Male, aged thirty-
six years. — Cough and stinking expectoration three
years. Temporary paresis of right hand. Four days
later, shivering, right hemiplegia, aphasia. Constipation
and involuntary micturition. Intense frontal headache.
No vomiting ; pulse 52, temperature 98.6°. Rigidity
of left arm. Died comatose. Multiple abscesses in
brain. One in right occipital lobe, and two in the
left hemisphere, one of which was close to the cortex.
Infectioti of Brain Substance.
In speaking of meningitis I have already
indicated how infection reaches the interior of
the skull ; and how the meninges react towards
it. I have now to speak of the effects of infec-
tion of the brain substance.
Like meningitis, brain abscess may be caused
by infection reaching the brain by direct con-
tinuity from an infective lesion in the head, or
conveyed indirectly by blood-vessel or lymphatic
OF ABSCESS OF THE BRAIN 93
from a local lesion in the head or elsewhere, or
may occur as part of a general infection of the
blood.
The oft- quoted statistics of Newton Pitt
show that nearly one half of all brain abscesses
are secondary to local disease of the cranial
bones, while only a small proportion of menin-
gitis cases have a similar origin. To reach
the brain by direct continuity from extension
of a local infective cranial lesion infection must
first traverse the meninges. In a rapidly ex-
tending infective process diffuse meningitis would
be the most probable result ; in the more slowly
spreading infection resulting from chronic disease
the meningeal infection would be localised by
adhesions and time given for extension of disease
to the brain.
The same point is illustrated by the fact
that abscess of the brain or sinus infection is a
more common complication of chronic ear
disease than is acute suppurative meningitis,
whereas meningitis has been the most usual
result in those cases, now happily rarely met
with, in which attempts to extract a foreign
body from the ear have been so unskilfully
made that intra- cranial infection has followed.
Here the meninges are directly infected, as in
accidental injury.
94 SOME POINTS IN THE SURGERY
In most cases of slowly spreading infection
from chronic disease adhesions occur obliterating
the cavity of the arachnoid at the site of infec-
tion and binding together dura, arachnoid, pia,
and cortex. The lymphatic sheaths of the
numerous small blood-vessels which traverse
the cortex at right angles to its surface are in
direct communication with the sub-arachnoid
space, and through these, as through a number
of capillary tubes, infective matter easily traverses
the cortex and reaches the white substance within.
The cortex is very vascular, and its connective
tissue element, reinforced by numerous prolonga-
tions from the pia mater, is abundantly supplied
with connective tissue corpuscles. Hence it is
able to offer a strenuous resistance to the bacterial
attack, and does not ordinarily undergo any ex-
tensive destruction. Where it is traversed by
the infective material a barrier of fibrous tissue
is thrown out, limiting the destructive process to
the formation of a narrow track.
The white substance is much less resistant,
and it would seem that the greater the distance
from the cortex the more easily does bacterial
action cause dissolution of brain substance.
Thus the abscess comes to assume a mush-
room-like shape, with the narrow portion or
stem attached to the dura at the original site
OF ABSCESS OF THE BRAIN 95
of infection from the bone. Preysing's figures
admirably illustrate this important fact.
When the dura has been separated from the
bone over a more or less considerable area
adhesion of the meninges takes place to a much
greater extent.
In a case successfully operated upon by Salzer,
an area of the dura over the temporo-sphenoidal
lobe measuring several square centimetres w^as
in a sloughy condition. The diseased portion
was excised, and the meninges were found fused
into one layer, the inner portion of which,
corresponding to the pia, was not necrotic.
There was no abscess of brain.
In a similar case, reported by Manasse, the
infection had proceeded a stage further and
there was an abscess of brain, the outer wall
of which was, over a considerable area, formed
by fused meninges and brain cortex.
The more recent the abscess the nearer will
it lie to the spot where the infection traversed
the dura, and the more evident will be the stalk
or its remains. The older the abscess the
greater is the apparent recession from the dura
and the less evident the remains of the stalk.
Such is the ordinary course of the formation
of brain abscess when, as is usual, the infection
gradually spreads into the brain substance by
96 SOME POINTS IN THE SURGERY
slow extension in direct continuity from the
spot where the disease in the bone reached
the interior of the skull ; but, as has already-
been stated, the infective particles may, in the
brain, as in other parts of the body, be carried
by the circulation to a spot remote from the
site of infection.
An abscess may thus arise in the substance
of the brain without having any visible con-
nection with the bone disease to which it really
owes its origin. Just as an abscess in the axilla
may arise from infection in the linger tip without
visible intermediate lesion.
The stalked form of brain abscess is quite
comparable, as to its mode of formation, to a
superficial cervical abscess connected by a narrow
track to a focus of disease beneath the deep fascia,
and the isolated variety of brain abscess has its
parallel in an abscess of liver arising from disease
in the intestine.
No difficulty need therefore arise in explain-
ing the pathology of a case reported by Swain,
in which purulent infection of the choroid
plexus in the descending cornu of the lateral
ventricle occurred as a result of caries of the
tegmen tympani of the same side, the inter-
vening brain substance being unaffected.
The abscess may more or less rapidly increase
OF ABSCESS OF THE BRAIN 97
in size and ultimately leak, either into the
ventricles or on to the surface of the brain.
Or it may run an entirely chronic course,
with more or less complete latency so far as
symptoms are concerned.
In these circumstances the abscess may or
may not become encapsuled. Encapsulation of
abscess appears to be relatively more frequent
in the brain than in other parts of the body.
This is due, not to any difference in the
pathological process, but to the peculiar liquid
texture of the brain, allowing a sharper differ-
entiation between the sclerotic tissue forming
the abscess wall and the surrounding unaltered
brain substance.
The statement that only acutely developing
brain abscesses are free from encapsulation is
too absolute, and a history of long- continued
cerebral symptoms in a case of brain abscess
does not necessarily point to the presence of a
capsule ; for in a case of cerebellar abscess with
symptoms pointing to a duration of at least
eight months no capsule was found, but the
whole cerebellar hemisphere was nothing but
a shell of softened grey matter.
An abscess completely latent as regards
symptoms for any length of time will usually
be encapsuled. An abscess in the brain, as in
H
98 SOME POINTS IN THE SURGERY
other parts of the body, may tend slowly to
extend, causing great local destruction of tissue.
Such abscesses give rise to slight symptoms
extending over a considerable period, and are
not encapsuled.
A slowly growing abscess may be thought
of as displacing or pushing aside fibres passing
from the cortex to the internal capsule rather
than causing their actual destruction, and this,
view is somewhat supported by the fact that
recovery from paralysis takes place after success-
ful drainage of the abscess. It must, however,
be pointed out that cortical impulses may some-
times find new paths.
When an abscess is drained through the
point of attachment to the dura, as in the case
of a temporo-sphenoidal abscess opened through
the tegmen tympani, though the abscess may
be large, there may be but little actual damage
to the cortex.
The formation of even a thick capsule does
not prevent the abscess from extending; nor even
from leaking into the ventricles. Acute inflam-
matory softening or even suppuration has been
known to arise around an encapsuled abscess.
Abscesses surrounded with a thick capsule
and which can be shelled out whole have run
a chronic course. Complete encapsulation of an
OF ABSCESS OF THE BRAIN 99
abscess arising by extension of infection by direct
continuity from bone may and does occur, the
narrow track of communication being obliterated
by scar tissue, just as in an aneurism, in process of
cure, the narrow orifice of communication with
the lumen of the artery becomes obliterated.
In these cases we should find adhesion of the
abscess wall to the bone.
When an abscess is found in the brain com-
pletely isolated and at some distance from the
meninges, the infective organisms have been
carried by the blood or lymph stream, and have
first multiplied at a spot in the brain some
distance from the point of infection.
Many of the cases published have resulted
from injury, not from bone disease, a consider-
able number having followed gunshot wounds.
In these, at least, it is conceivable that infec-
tive particles have been driven directly into the
substance of the brain, in fact that a " stab-
culture " has been made.
The following is a good instance of encapsuled
abscess (Bergmann) : —
A youth, aged sixteen years, received a pistol-shot
wound in the right frontal region. Four months after-
wards the right frontal lobe was explored for abscess,
several punctures being made with a needle. No pus
was reached. Three days later the abscess burst. The
loo SOME POINTS IN THE SURGERY
opening was enlarged with a scalpel. So thick and
firm was the capsule that it was dragged out whole.
Three days later the symptoms recurred. A second
encapsuled abscess was opened and the capsule likewise
dragged out. On the death of the patient, six weeks
Fig. 42. — Spreading septic softening of the right frontal lobe. (Hooper, 1826.)
Lebert gives a good illustration of the same condition in the cerebellar hemi-
sphere. I think that this particular result of septic infection occurs more readily
and is more dangerous in the cerebellum than in the cerebrum. The brain, just
like any other soft tissue of the body, may be affected by localised or by spreading
suppuration.
later, from pyelitis, the wound in the brain was found to
be healing well.
Spontaneous Recovery in certain Tubercular Cases.
Inspissation and even calcification of brain
abscess has been observed, but only in tuber-
cular cases, the occasional spontaneous cure of
which cannot be denied.
OF ABSCESS OF THE BRAIN loi
Cases are relatively common in early life
which, although the symptoms are apparently
only explicable by the presence of a cerebral
tumour or of meningitis, either get well or run
Fig. 43. — Encysted abscess of left frontal lobe. (Hooper, 1826.)
The cyst -wall was as thick as the pericardium. The cyst contained between
2 and 3 oz. of pus. Von Bergmann's case is a good example of encysted abscesses of
the frontal lobe. I have known an abscess of the frontal lobe to have so thick a
wall that it could be rolled about the floor like a billiard ball.
a chronic course extending over many years, and
then die from distension of ventricles.
In some at least of these cases it seems probable
that there was a localised tubercular mass in the
brain which has been recovered from.
In one such case, some four years after a
diagnosis of cerebral tumour had been made, the
autopsy showed great distension of ventricles.
I02 SOME POINTS IN THE SURGERY
There was no visible tumour and no evident
trace of tubercle in the brain, but in the
mesentery there was a large calcareous
mass.
Two girls, under twenty years of age, both
suffered from headache, vertigo, nystagmus, and
repeated purposeless vomiting ; both had double
optic neuritis, unsteady gait, and absence of the
patellar reflex. The diagnosis in both cases was
some affection below the tentorium, probably
cerebellar tumour. Both made good recoveries,
but in one some impairment of sight remained.
Multiple Brain Abscess (apart from General
Pycemia) .
Multiple brain abscess does not commonly
occur as a result of injury, indeed the abscess
which follows an injury is usually a meningo-
cortical abscess.
A second abscess in the temporo-sphenoidal
lobe is rare. Probably in some at least of the
published cases the second abscess was nothing but
a pocket of the original abscess. In Kiimmel's
case, however, the autopsy showed a second
abscess separated by a thick capsule from the
first. In Roncali's case a temporo-sphenoidal
abscess extended into the frontal lobe. In a
OF ABSCESS OF THE BRAIN 103
case of my own a temporo-sphenoidal abscess
had extended into the occipital lobe.
A second or even a third abscess in the cere-
bellum is by no means uncommon. The first
abscess is usually situated in the anterior and
outer part of the lateral hemisphere. A second
abscess may be situated internal to the first and
separate from it ; or posterior to it, in which
latter case it has probably been originally con-
nected with it, so that the apparently double
abscess is really a single dumb-bell shaped
cavity.
Another type of second abscess met with in
the cerebellum is the oyster-shaped abscess.
This forms beneath the grey matter of the
upper surface. It occupies an extensive area
laterally and antero-posteriorly, but in depth is
very shallow.
When a second or third abscess has not arisen
by infection from, or extension of, the first, it has
a separate point of attachment to the dura at the
site of infection.
I have elsewhere pointed out that the
statistics of St. Thomas' and Great Ormond
Street Hospitals show that abscess of aural
origin is more frequent in the cerebellum than
in the temporo-sphenoidal lobe. The following
suggestions may be oflfered as an explanation of
I04 SOME POINTS IN THE SURGERY
this, and of the fact that abscess resulting from
disease of the temporal bone is more frequently
multiple in the cerebellum than in the temporo-
sphenoidal lobe.
In the middle fossa the site of infection is
practically limited to the roof of the tympanum
and antrum, while in the posterior fossa infection
may occur anywhere along the whole posterior
surface of the petrous or the groove of the sinus.
Not only is there a larger bone area where
infection can enter, but there is a larger surface
from which septic absorption can take place, for
if both were spread out, the superficial area of
the folia of the cerebellum, in. relation to the
posterior surface of the petrous, would greatly
exceed that of the convolutions of the temporo-
sphenoidal lobe in relation to the tegmen.
Again, since the pia mater runs to the bottom
of every fissure between the folia, and also lines
the deeper fissures between the lobes, it, when
infected, carries septic material deeply into the
cerebellum, hence the opportunity for the
branching of the track of infection or the for-
mation of two distinct tracks.
Abscess has been met with at the same time,
both in the temporo-sphenoidal lobe and in the
cerebellum.
The great morbid anatomists of the last
OF ABSCESS OF THE BRAIN 105
generation — Auvert, Cruveilhier, Lebert, Bright,
Hooper, and Carswell — all contribute beautiful
illustrations of abscess of the brain. How
splendid were their labours, and how much we
Fig. 44. — Abscess of the right temporo-sphenoidal lobe. (Cruveilhier, 1830.)
Male, aged 32 years. Pain and discharge from right ear for 20 years. April 18,
1829. — Taken ill with violent headache and fever. April 29. — Seen by Cruveilhier.
No affection of sensation movement or intelligence. Died suddenly May 11.
Cruveilhier states that the grasp of the two hands the day before death was equal,
so there could not have been any gross hemiplegia.
Autopsy. — The ventricles were full of pus, but the encysted abscess had no con-
nection with the ventricles. The last illness was probably meningitis and acute
infection of the ependyma of the ventricles — a new infection — from the petrosal
disease. The encysted abscess, as we often find, was not the immediate cause
of death.
are indebted to them ! On the sure foundation
laid by such patient pathological investigations
the more perfect clinical diagnosis of the present
day has been built up, and the recent advances
io6 SOME POINTS IN THE SURGERY
of surgery have in great measure been made
possible.
The Symptoms of Brain Abscess.
If we appreciate the march of the symptoms
arising when abscess occurs anywhere we shall
have the key to the understanding of the
symptoms of abscess when situated in the brain.
The symptoms of abscess in any region, as, for
example, in the axilla, can naturally be grouped
in three divisions : —
1. Those due to the infective process itself.
2. Those common to infective lesions of the
anatomical region involved, and
3. Those due to specific functional disturb-
ances caused by the local lesion or its influence
on the surrounding tissues.
We may then classify the symptoms of brain
abscess as follows : —
1. Those due to the mere presence in the
body of deep-seated pus independent of its locality.
Such as the febrile state, with perhaps shiver-
ing and vomiting.
2. Those due to increase of tension within the
closed cavity of the skull.
Such as purposeless vomiting, slow pulse,
torpor.
3. Those due to irritation or suppression of
OF ABSCESS OF THE BRAIN 107
function of particular parts of the central nervous
system.
Such as epilepsy, anesthesia, paralysis, and
perversion or loss of one or other of the special
senses.
Symptoms of Extra-Dural Suppuration.
Suppuration between the bone and dura gives
rise to no specific symptoms, and the first indica-
tion of the presence of an extra-dural abscess is
often the discovery of the pus during the course
of an operation for disease of the bone.
When the pus happens to be under tension
there is much local pain and fever, possibly
there may be tenderness on percussion over the
site of the abscess, and there is often rigidity of
neck when the suppuration is in the posterior
fossa. Sometimes symptoms arise from compres-
sion of the brain, but there is then nothing to
distinguish extra-dural from intra-dural suppura-
tion. When the infection is virulent enough to
rapidly make its way through the dura, the pus
not being under tension, the extra-dural stage of
the progress of the case is not commonly marked
by any recognisable symptoms.
The symptoms of brain abscess are sometimes
pathognomonic as to its situation, in others they
are in this respect indefinite, and the diagnosis of
io8 SOME POINTS IN THE SURGERY
the seat of the abscess, if possible at all, has to be
made from the attending circumstances rather
than from the direct effects of the abscess on the
brain.
I shall not have time to deal with the localis-
FiG. 45.
Fig. 46.
Figs. 45, 46. — The cortical centre for hearing. (Ferrier.)
The superior temporo-sphenoidal convolution was destroyed in both sides in the
monkey, causing complete deafness. The animal was allowed to survive for more
than a year, during which time it enjoyed perfect health and the full enjoyment of
all its faculties, with the single exception of hearing.
ing symptoms of brain abscess, and this is the
more unnecessary as I have elsewhere done so in
some detail, and the subject has moreover been
fully discussed by many other observers. I pro-
pose only to illustrate the application of localising
OF ABSCESS OF THE BRAIN 109
symptoms to diagnosis by discussing those pro-
duced by abscess or tumour of the temporo-
sphenoidal lobe either by disturbance of cortical
Fig. 47.
Figs. 47, 48. — The cortical centres for taste and smell. (Ferrier.)
Lesions of right and left hemisphere, causing in the monkey loss of taste and
smell. In the right hemisphere the shading indicates the extent of destruction of
the grey matter. In the left hemisphere the dark shading indicates the superficial
extent of the wound, and the dotted lines the extent of internal destruction of the
lower portion of the temporo-sphenoidal lobe.
centres or by pressure on adjacent parts of the
brain.
I. The cortical centre for hearing may be
no SOME POINTS IN THE SURGERY
in part or wholly involved, causing tinnitus,
hyperacusia, or absolute deafness of the opposite
(healthy) ear, all of v^hich symptoms I have
observed.
2. The cortical centres for taste and smell
may be affected. Alteration or suppression of
the sense of smell may occur in abscess, involving
the anterior extremity of the temporo-sphenoidal
lobe. Some cases illustrating the cortical local-
isation of the sense of smell are given farther on.
Jackson and Beevor published, in 1887, a remark-
able case of tumour of the tip of the right temporo-
sphenoidal lobe, confirming clinically Ferrier's
classical experiments. Their patient suffered
from fits, associated with the dreamy state (com-
monly called intellectual aura), and a crude
sensation of smell. I have observed the dream
state in several cases of temporo - sphenoidal
abscess.
3. Sensory aphasia often occurs in abscess of
the left temporo-sphenoidal lobe in consequence
of the cortical centres for the mechanism of
speech being on the left side of the brain. The
auditory word centre and the visual word centre
are the ones involved in temporo-sphenoidal
abscess. A temporo-sphenoidal abscess on the
left side is therefore commonly more easy to
recognise than one on the right.
OF ABSCESS OF THE BRAIN iii
4. Paralysis of the opposite side of the
body may be of cortical or internal capsule
type. The march of the paralysis is different
in the two cases. This paralysis is a frequent
occurrence from pressure on the posterior
end of the internal capsule, and may be
associated, as might be expected, with hemi-
anesthesia.
5. Paralysis of the third nerve on the side of
the abscess. This is important. The paralysis
is rarely complete. A stabile pupil on the side
of the suspected abscess clenches the diagnosis.
6. Paralysis of the " naming centre."
Certain clinical and pathological observations
point to the conclusion that the nervous mechan-
ism by which the ideas of objects are correlated
with their names, is located in the left tem-
poro-sphenoidal lobe.
The formation of an idea of an external
object is the combination of the evidence re-
specting it received through all the senses ; and
for the employment of this idea in intellectual
operations it must be associated with and sym-
bolised by a name. Broadbent and Charcot
thought a naming centre necessary for the
receipt and combination of the sensory impulses
involved. Ross and Bastian do not think so.
112 SOME POINTS IN THE SURGERY
Cases Suggestive of Site of Naming Centre}
I . A woman, aged forty years, became in a high degree
word blind after a cerebral seizure, though not letter
blind. She could not name objects she recognised by
sight and by touch. On one occasion she called the
scissors "what I sew with," and the purse "what I buy
Fig. 49.
Fig. 50.
Fig. 49. — Diagram of the position in the cerebral cortex of the centres concerned
in the mechanism of speech. (IVIills.)
A, Auditory centre (centre for word hearing) ; V, visual centre (centre for word-
seeing) 5 N, naming centre (centre where percepts are given a name) ; B, motor-
speech centre (in Broca's convolution) ; G, graphic centre ; U, utterance centre.
Fig. 50. — Tumour of the 3rcl temporal convolution, indicating the position
of the naming-centre. (Mills.)
A, Densest, and probably oldest portion of the growth (the cortical limit of the lesion
is indicated by the dotted lines) ; B, anterior limit of the lesion beneath the cortex.
with." At the autopsy a tumour was found involving
the third left temporal convolution (Mills).
2. Captain M., aged forty-four years, suffered six
weeks before I saw him with an inflamed throat, pain in
the left ear, and left otitis media. For ten days he had
had pains in the head and vertigo. Pus could be seen
oozing from a perforation in the lower part of the
drum. For a fortnight hot fomentations and anti-
septic irrigation were employed, and at the end of that
time the patient returned without headache, but still
1 See page i 54 for another case of anomia.
OF ABSCESS OF THE BRAIN 113
with otorrhoea and vertigo. The complete mastoid
operation was then done. As the tegmen was carious
it was removed. The dura over the tegmen was
inflamed and not pulsating normally. For a fort-
night all went well. The patient was out daily and ap-
peared to be convalescing. The temperature then rose
to lO] ^ and the patient was sick. Next morning he was
Fig. 51. — Capt. M. Case illustrating site of naming centre.
a. Granulating cerebral cortex seen through opening in dura covering region of
tegmen tympani three weeks after operation. (From a photograph by A. C. Ballance.)
To discover the "stalk" and evaciiate the contents of a temporo- sphenoidal
abscess the operator removes the tegmen tympani.
irritable, temperature ^9°, general headache, and feeling
of nausea. Suddenly he was much perturbed by being
unable to name anv object or person, though still able
to converse in a somewhat confused manner. This
condition, in its worst form, lasted about two hours.
In the evening the exposed dura was bulging, headache
and nausea continued, vomiting was repeated, and both
discs were congested. An anassthetic was given, and
I
114 SOME POINTS IN THE SURGERY
the bulging dura incised. The membranes and cere-
bral cortex were fused together, and on passing the
little finger through the dura a cavity in the cerebral
cortex was entered about the size and shape of a
thimble. No actual pus was seen. The brain around
the cavity was soft, and incisions were made in it.
Lumbar puncture was done, the fluid contained poly-
nuclear leucocvtes in abundance, and it was feared that
meningitis had set in. The cavity probably occupied
the temporo-occipital convolution and the adjoining
part of the third temporal convolution, so interfering
with Mills' " naming centre." The patient made a
rapid and complete recovery.
Preysing has published a somewhat similar
case.
3. A woman, aged thirty years, had had chronic sup-
puration in the left ear for twenty-four years. Three
days before Preysing saw her the discharge ceased
suddenly, and from that time there had been severe
pain behind the ear and in the temporal region. The
meatus was somewhat narrowed by inflammatory
swelling, and a small amount of fetid pus was found in
it. Complete mastoid operation next day. A week
later the middle fossa was opened by removing the
tegmen tympani and antri. Dura granulating and
perforated, some pus escaped from the temporo-
sphenoidal lobe. Next day fever and headache per-
sisted, the wound was explored, and a further extension
of the abscess opened up with forceps. Some difiiculty
was experienced in establishing satisfactory drainage.
In the evening the fever had subsided and the patient
felt well, but was astonished by finding that she was
unable to give her address, she could only say " It is
OF ABSCESS OF THE BRAIN 115
in the narrow street close by the church." She could
not even recognise the name of the street when it was
told her, but answered, "No, that is not the street."
On investigation it was found that she was unable to
name any countries, towns, or streets ; though she could
describe those with which she was familiar. She did
not always recognise the names when she heard them.
Ordinary objects were, with few exceptions, correctly
named. This partial loss of the power of naming
persisted for about a week. For about another fort-
night she was unable, after reading a short paragraph,
to say what it was about ; the meaning of the lines
being forgotten almost as soon as they were read.
In three months from the time of the first operation
recovery was complete.
Brissaud and Souques, in their interesting and
lucid exposition of language defects resulting
from brain disease, say : — " Complete inability
to utter any vocal sound, articulate or inar-
ticulate, is quite exceptional. Complete loss of
articulate speech, with ability to make use of
guttural sounds of low or high pitch, is often
enough observed."
Some aphasics are only able to pronounce
isolated vowels or consonants, such as A, O, R,
S, or, as is most usual, only meaningless syllables
or grotesque words, which they keep on repeating.-^
1 As illustrations of such syllables and words the authors give '■'■ af,far,
^Mat, cousin, akoko, monomeme?itif, iquifofoiqui " ; these with, of course, the
French pronounciation aptly represent the mumbling's of certain aphasics.
ii6 SOME POINTS IN THE SURGERY
Others, again, retain nothing of their native
tongue but oaths and expressions of the most
objectionable nature. Some have saved from
the wreck a few castaways, fragments of words,
generally the first syllables ; and sometimes this
partial aphemia is limited to substantives. Such
was the case, related by Trousseau, of the
eminent lawyer who said " Give me my um —
um — um — damnation ! " " Your umbrella ? "
" Ah, yes, just so, my umbrella."
Aphemia limited to one particular part of
speech, the substantive, the verb, etc., is by no
means rare. Most commonly it is the noun,
"•' the substance of discourse," that is the most
completely lost. The Abbe Perier,^ wishing to
ask for his hat, could only say, " Give me
my . . . what is hanging on the . . ." Loss
of memory of verbs is not common, the speech
then becomes a sort of " nigger language," or
pidgin English. A patient of Voisin lost all the
personal pronouns, which he replaced by " one " ;
speaking of himself, he would say, " One would
1 Piorry, who published this case in 1838, thus described loss of memory
of names as a particular form of speech defect sometimes met with in
cerebral hasmorrhage : — " Some patients who have had cerebral haemorrhage
recollect incidents perfectly well, have an exact memory of places, things,
sounds, etc., but if asked to give the name of a person whom they know
very well are unable to recollect or to pronounce the name. In a more
advanced stage of the affection they cannot even assign to anything the
noun used to designate it."
OF ABSCESS OF THE BRAIN 117
like something to eat," " One is not feeling well."
Aphemia generally obeys the law of progressive
loss of memory, going from the particular to the
general; proper nouns are first lost, then concrete
and abstract nouns, adjectives, and adverbs.
Some observations (Bouillaud, Winslow, Voisin)
form exceptions to this rule.
" One of Charcot's patients was completely
aphasic for Italian and Spanish, which she spoke
quite fluently before her illness, but retained the
power of speaking French, which was not her
native language. That is, however, an ex-
ception ; the native language is usually the last
to be lost. There is likewise an aphemia for
figures and numbers, for musical notes, etc.,
sometimes these various varieties co-exist, some-
times they occur independently. A very in-
teresting form of motor aphasia results from the
fact that the words of a familiar song become
so closely associated with the corresponding
musical notes that words and music come to
form one complete whole ; so that, for example,
an aphasic quite unable to recite the words of
the Marseillaise, would sing them without fault
on hearing the music. The centre of ideation
common to the words and the musical sounds
being able to set in action the motor impulses
for phonation."
ii8 SOME POINTS IN THE SURGERY
Brissaud and Souques do not appear to re-
cognise the existence of a separate naming centre.
They quote Pitres to the following effect : —
" Patients affected with amnesic aphasia have not
absolutely lost the power of speech, often enough
they speak a great deal. They can read both
mentally and aloud. They understand what is
said to them. They give accurate replies to
questions. But from time to time the words
they desire to employ to express their thoughts
escape their memory, and they are obliged to
stop or make use of a paraphrase. It is quite
natural that the lesions giving rise to amnesic
aphasia should be sought in the immediate
vicinity of the sensory word centres, but they
have no absolutely fixed localisation. Indeed
the symptoms seem to be caused, not by de-
struction of a highly specialised centre exclusively
devoted to the recall of words, but by interrup-
tion of some or other of the commissural fibres
uniting the special centres for verbal images
with those parts of the cortex concerned in the
higher psychic functions."
" Ballet thinks that amnesic aphasia is due to
diminished functional activity of centres specially
differentiated for the preservation and reproduc-
tion of word images.
" Dejerine does not consider it a special form
OF ABSCESS OF THE BRAIN 119
of aphasia, but merely an attenuated form of
motor or sensory aphasia into which it passes by
insensible gradations."
Thus it is evident that though partial defects
of speech in incomplete forms of aphasia are
explained by some as consequent on lesions of
definite centres, yet this view remains unproved,
and is not accepted by other prominent neuro-
logists.
Centres for intonation, equilibration, and
orientation have been located in the temporo-
sphenoidal lobe. Time will not permit me to
discuss them now.
Other cases illustrating the localising symp-
toms of temporo-sphenoidal disease : —
1. Man, aged thirty-eight years. Operation for left
petro-mastoid disease. Three days later he complained
that everything given or shown to him had a bad smell.
One day he asked the Sister to boil a sixpence (he had
previously been in the habit of giving his wife sixpence
to buy eggs). The day after this he had aphasia
agraphia, alexia ; he had vomited, and there was weak-
ness of face and arm with exaggeration of the knee-
jerk on the contra-lateral side. At the operation the
whole of the left temporo-sphenoidal lobe was found
occupied by an abscess. (Case under treatment ten
years ago.)
2. A woman, aged twenty, was quite unconscious of
having been removed to the hospital, and repeated
I20 SOME POINTS IN THE SURGERY
exactly the same words as when she was in bed at home.
She lay quietly on her side with the limbs flexed, occa-
sionally moaning, and taking no notice of anything
around her. She could be roused with difficulty, and
she then sat up in bed with a vacant expression of
countenance, the eyes staring straight in front of her, and
being apparently unconscious of her surroundings she
said slowly, " Am I dying ? " " Where am I ? " Then
she sank back on the pillow till again roused, when the
same result followed, and the same words were repeated.
The abscess was in the left temporo-sphenoidal lobe.
This case illustrates the condition known as the dream
state,
3. A man, aged forty-eight, was admitted to St.
Thomas's some years ago with chronic otorrhoea on the
right side. He had lost a son the year before from
cerebellar abscess. The patient was a gardener, and said
that for three weeks he had had slight headache and
had once vomited. His main complaint, however, was
that he had lost the sense of smell, being unable to dis-
tinguish in this way between roses and violets. On
examination the right pupil was found to be stabile and
the right disc blurred. Operation forthwith. A large
abscess was drained through the stalk, which was adherent
to the diseased tegmen tympani. Rapid convalescence.
No hernia cerebri. Recovery of sense of smell.
4. A man, aged thirty-eight, was seen six years ago.
Hewas of considerable intellectual attainments and a good
pianist. He had had left chronic otorrhoea since early
childhood. Ten days previously a polypus had been
removed from the ear by an otologist. Shortly afterwards
he began to suffer from headache and vomiting. When
seen by me pus was pouring from the left meatus in
such quantity that it was obviously coming from a large
OF ABSCESS OF THE BRAIN 121
cavity. He had also aphasia, agraphia, alexia, and
amusia. The left pupil was stabile and the right face
weak. Operation forthwith. Large abscess evacuated.
Complete recovery, with the exception that the loss of
the appreciation of musical sounds remained permanent.
5. Tumour of the right temporo-sphenoidal lobe
(Beevor and Jackson), Female, aged fifty-three years.
Fig. 52. — Tumour of the right temporo-sphenoidal lobe bearing on the
localisation of the sense of smell. (Jackson and Beevor.)
M'Lane Hamilton {New York Medical Journal, 1882) published a case of cortical
sensory discharging lesion, in which disease involved the tip of the temporo-sphenoidal
lobe. Before being convulsed, the patient, a woman aet. 40, had a peculiar aura :
she suddenly perceived a fetid odour.
For thirteen months before her admission to hospital
she had had epileptic fits. The patient, who was a
cook, had peculiar seizures in which she saw a little
black woman who seemed to be always very actively
engaged in cooking. She had also the subjective sensa-
tion of a horrible smell. She would stand with her
eyes fixed and directed forwards (dream state) and
122 SOME POINTS IN THE SURGERY
then say, " Oh, what a horrible smell ! " There was
some droophig of the left side of the face, and the
tongue when protruded deviated to the left.
Autopsy. — The whole of the anterior end of the
hippocampal lobule on the right side was occupied by
a tumour. It involved the amygdaloid nucleus and the
central white matter, but did not affect the grey cortex
of the hippocampal convolution or of the first temporo-
sphenoidal convolution. The nucleus lenticularis and
the anterior end of the internal capsule were compressed.
Hence the weakness of the opposite side of the face
and the deviation of the tongue to the left. The left
arm and leg became paralysed shortly before death.
The extreme anterior end of the temporo-sphenoidal
lobe is the hippocampal lobule, which is highly de-
veloped in macrosmatic animals and rudimentary in
microsmatic animals like the dolphin.
6. Rone all s case. — A man, aged thirty-eight years, had
severe pain in the right mastoid region following an
attack of facial erysipelas. The tympanic membrane
was incised. The patient had had two previous attacks
of erysipelas, but gave no history of having formerly
had ear disease.
Ten days after the incision of the tympanic mem-
brane a severe epileptic fit occurred, leaving the patient
prostrate for several days. A week or so after the fit
there was high fever, and an abscess formed over the
right mastoid region which soon burst externally, giving
exit to a considerable quantity of pus. For a short
time the occipital and frontal headache of which the
patient complained were much relieved, but soon
recurred with increased severity. The man then
entered an hospital, where the mastoid operation was
done ; this, of course, gave no relief, since the disease
OF ABSCESS OF THE BRAIN 123
was in the brain, and when the wound had cicatrised
the patient was worse than ever. The headache became
more severe and vomiting occurred several times daily ;
the least noise or the ordinary daylight caused intense
distress, and the general health steadily deteriorated.
In this state he was sent to an aural specialist in
Rome, who diagnosed brain abscess, and at once pro-
ceeded to try to open it through the mastoid ; after several
attempts he succeeded in finding, at the lower level of
the middle fossa, a fistulous opening in the squama
through which pus came. This he enlarged to the size
of a sixpence and incised the dura. A hundred c.c.
of pus came away. A plug of gauze was inserted into
the abscess cavity through the fistula. The temperature
kept high for a few days. On the third day, when the
dressing was removed and the plug pulled out, 50 c.c.
of pus came away. After this the patient improved,
and a fortnight later he left the hospital and became an
out-patient. The mastoid wound healed up very
quickly. The fistulous track became partly blocked
by granulations but did not close, and at every dressing
a considerable quantity of pus escaped through it.
If it was not at first obvious that the opening in the
skull was insufficient to drain the abscess, this was soon
rendered evident by the subsequent course of the case.
The discharge continued without diminution, and
symptoms of local brain lesion were added. Vertigo,
violent headache extending all over the right side of the
head, epileptic fits beginning with movement of the
toes on the left side and preceded by hallucinations of
smel^, were prominent symptoms. In spite of all this
no attempt was made for twenty months to open up
the skull and evacuate the brain abscess. Six " opera-
tions " limited to curetting the wound and irritating the
124 SOME POINTS IN THE SURGERY
fistulous opening with the cautery were performed.
Irrigation was attempted through a tiny silver tube
inserted through the little opening in the skull.
After this lamentable waste of time and opportunity
the patient, then in a very feeble state, came under the
care of Roncali, who came to the conclusion that there
must be a large abscess in the frontal lobe extending
backwards to the Rolandic area. Making a free open-
ing in the skull, he found and opened the upper abscess
shown in the figure. Ninety c.c. of pus were let out. The
Fig. 53. — Abscess in the temporal and frontal lobes.
(Roncali, in Chipault, vol. iii.)
The sphenoidal stalk, which was irrigated daily for so long, is seen. By this
treatment, no doubt, at last pus was squirted into the frontal lobe.
cavity was explored with the finger and seemed as large
as an egg ; it was irrigated through the fistula and
through the wound until no more pus escaped from the
fistula.
For two days all went well. On the third day there
was fever, followed by drowsiness. Wound dressed ;
no pus came from the abscess cavity, but some was
seen trickling through the old fistula. Another fit
occurred that day, preceded by olfactory aura. Next
day more bone removed. A knife was inserted into
the fistula and brought out through the already open
abscess cavity. All intervening structures were divided ;
OF ABSCESS OF THE BRAIN 125
the track was very dense and offered great resistance to
the knife. On washing the track thus laid open the
dilatation of the sphenoidal stalk shown in the figure
was seen. Two small orifices through which pus
trickled opened into the upper part of the dilatation,
a probe-pointed bistoury was inserted through each into
the cavity beyond and an incision made downwards.
Eighty c.c. of fetid pus were let out. Improvement for
three days, then rise of temperature and death on the
seventh day, probably from suppurative meningitis.
This case illustrates : some symptoms of temporo-
sphenoidal abscess, namely, hyperacusia, and fits preceded
by an olfactory aura ; the uselessness of operation
limited to a cranial bone when the brain is suppurating ;
the pernicious effect of syringing a brain abscess through
a small tube whereby in this patient the pus was driven
from the temporal into the frontal lobe ; and the fatal
result necessarily attending a case of brain abscess when
dealt with in a manner contrary to the principles govern-
ing the treatment of abscess in other parts of the body.
When the case came under Roncali's care it was too
late to save life, but the measures he adopted were
conceived in the true spirit of surgery.
Clijtical Evolution and Diagnosis.
The evolution of abscess wherever situated
varies greatly. The initial local infection may
be quickly subdued and a small local abscess
alone result, well isolated, and giving the patient
little more inconvenience than an encysted sterile
foreign body ; or the abscess may slowly extend
and burst, with favourable or unfavourable
126 SOME POINTS IN THE SURGERY
results according to the seat of rupture ; or the
abscess may extend acutely from the first with
severe or even fatal general infection ; the symp-
toms— both those due to the abscess as such,
and those due to the local lesion — necessarily
vary in these different eventualities.
So in cerebral suppuration the complexity
of the symptoms is not due to any peculiarity
in the pathology of suppuration in the brain,
but to the complex functions of the organ
involved.
As abscess of the brain is a secondary and
not a primary disease, the problem of diagnosis
is often rendered the more difficult owing to
the presence of symptoms which are, or may
be, due to the primary disease, or to some
of its complications. Suppuration in the brain,
like suppuration elsewhere, varies within wide
limits in its virulence and local destructive
effects ; there will from this cause be wide
differences in the clinical course of cases. The
moment when infection reaches the brain is not
commonly marked by any recognisable local
symptom.
We may adopt the five types of clinical
evolution so well described by Brissaud and
Souques.
I. A sub-acute evolution more or less distinctly
OF ABSCESS OF THE BRAIN 127
divided into three stages : the initial febrile
stage, the symptoms in which are those of septic
or febrile infection ; headache, vomiting, and
fever. Similar symptoms occur in the initial
stage of specific fevers, and the distinction may
at first prove difficult. This stage lasts a vari-
able number of days and corresponds to the
acute stage of the suppuration.
It is succeeded by the second stage, the stage
of remission. Sometimes suddenly, more often
gradually, the symptoms abate and give place
to a period of calm, which is the more deceptive
as it is sometimes prolonged. During this period,
though few or no symptoms are manifest, there
is, especially, as insisted on by Okada, when
the abscess is in the cerebellum, emaciation
and impairment of general health ; moreover, a
thorough examination would in most cases raise
the suspicion that gross brain disease was present
or unmask some pathognomonic localising sign.
The third or paralytic stage supervenes in
most cases suddenly as an " ictus " with or
without convulsion; the apoplectiform condition
may pass at once into profound coma terminating
fatally in a few hours, or recovery from the
seizure may take place with symptoms indicating
a local brain lesion.
With the onset of the third stage there is
128 SOME POINTS IN THE SURGERY
generally renewed fever. The more rapidly
fatal cases are associated with rupture of the
abscess, the others with more or less rapid
extension of the suppuration.
The above - described evolution of a brain
abscess in three stages is quite comparable to
the evolution of appendicular suppuration in
three stages not unfrequently observed in cases
not operated on in the initial stage. First there
are transient symptoms of onset, then a period
of quiet during which there is localised suppura-
tion, and finally renewal of symptoms due to
extension or rupture of the abscess.
2. The evolution with severe general infection. —
These are rapidly fatal cases — the symptoms of
brain abscess are merged in those of grave
general infection ; high fever and acute delirious
mania are prominent symptoms. Sometimes the
history or the manifest presence of one of the
known causes of brain abscess will arouse a
suspicion of the existence of that complication ;
more often the diagnosis is made of a malignant
form of some specific fever or the disease known
as acute delirious mania.
3. Evolution with complete latency until the
final attack of coma. — The patient dies suddenly
or in a few hours, and a brain abscess, evidently
having existed for a considerable time, is found
OF ABSCESS OF THE BRAIN 129
at the autopsy. In some such cases death is
absolutely sudden. According to Brissaud and
Souques the abscess will then be found in the
centre of the frontal lobe or in the postero-
external region of the occipital lobe. I should like
to point out that the right temporo-sphenoidal
lobe is a much more frequent and equally
" silent " site of abscess.
The term " latent " must not be misused in
connection with these cases ; symptoms not
noticed and symptoms not present are not
synonymous terms ; some of the manifestations
of gross disease of the brain cause the patient
but little inconvenience and are only elicited
by an attentive clinical examination. In but
few of the recorded cases of " complete latency "
is there any evidence that such examination has
been made, and in fewer still have the patients
been under skilled observation for a period of
several days during which pulse and temperature
have been regularly taken.
We all know that an examination of the optic
discs, the field of vision, and the actions of the
muscles of the eye, has revealed the gravity of an
illness which from the patient's complaints alone
might well have been considered trivial. And, on
the other hand, that the omission of such an ex-
amination has often led to an error in diagnosis.
K
I30 SOME POINTS IN THE SURGERY
No one would call an axillary abscess latent be-
cause there was no pressure on the brachial plexus.
Is it not possible that in at least some of the
latent cerebral cases the latency has been in the
faculties of the observer, not in the clinical
reactions of the patient ?
4. In the fourth type the clinical evolution is just
like that of brain tumour. — The infection is of low
virulence and the abscess produces just those
symptoms which a tumour growing in the same
region and at the same rate would cause.
5. The fifth type of evolution is the retnittent type.
— " Here the clinical evolution is in two acts,
separated by an entr'acte of greater or less dura-
tion. The first act is marked sometimes by
headache and fever, sometimes by an attack of
mania, sometimes by acute delirium. Then all
quiets down and the patient seems cured. But
after a few weeks, a few months, or even a year,
follows the second act, which is commonly
quickly fatal."
Bristowe's influenza cases previously referred
to are examples of this type of evolution.
Case I. — A man, aged twenty-four years, was ad-
mitted to hospital with right hemiplegia and paralysis of
the left third nerve. There was incontinence of urine.
Optic neuritis was present on both sides. The patient
was apathetic and did not speak or attempt to speak.
OF ABSCESS OF THE BRAIN 131
He died three days after admission. About two months
before admission he had an acute illness with shivering,
severe headache, and convulsions. At the autopsy
there was found in the upper part of the left fronto-
parietal region an encapsuled abscess as large as a
Tangerine orange, containing thick greenish pus. There
was no disease of the cranium.
Case 2. — A girl, aged fourteen, had, one month before
admission to hospital, an acute illness with shivering,
vomiting, and severe headache. From this she appar-
ently recovered in the course of a few days but she
did not quite lose her headache. Two months later
headache increased in severity and she had vomiting
from time to time. When admitted to hospital,
agonising pain in the head, rigidity of neck, left
pupil larger than right, no optic neuritis, no paralysis,
nor anesthesia. At the autopsy an abscess as large as
a Tangerine orange was found in the right occipito-
sphenoidal region, containing thick greenish pus. There
was a small communication between the abscess and the
descending cornu of the lateral ventricle which con-
tained about a drachm of pus. No cranial disease.
Another example was a case I saw with Dr.
James Taylor.
A man, aged forty years, was admitted to hospital on
Sept. 14th, 1895, ^'^^^ severe occipital pain, vomiting,
and slow cerebration. He had paralysis of the right
sixth nerve and double optic neuritis. He lay on his
right side in bed. There were forced movements to
the right with rotation to the right in walking. With
the eyes shut he fell backwards and to the right. In
the beginning of May in the same year he had a severe
132 SOME POINTS IN THE SURGERY
illness with shivering, sweating, and rigor, said to have
been of influenzal origin. This had been followed by-
slight loss of power on the left side, from which he had
recovered. About ten days before admission the head-
ache and other symptoms returned. On the day
following admission (September 15th) a rigor com-
menced at 5.30 P.M.; at 6.30 coma was complete; at
7.30 artificial respiration was necessary and was con-
tinued until I arrived. I was told that the case was
thought to be one of cerebellar tumour. Considering
it almost impracticable to remove a cerebellar tumour
during the performance of artificial respiration, and
thinking that the history of left -sided paresis might
indicate involvement of the right cerebral hemisphere,
I removed a large area of bone in the right parietal
region. The brain bulged under great pressure, but
natural respiration did not return. A trocar and
cannula was plunged in up to the hilt and impinged
upon a hard mass, into which it would not penetrate.
As this was thought to be a solid basal tumour which
could not be removed, the operation was abandoned.
The necropsy revealed an encapsuled abscess containing
an ounce of thick greenish pus, replacing the right
optic thalamus. The capsule was very firm and about
one-fourth of an inch thick. At the present day such
an abscess or tumour coming under my observation
would be enucleated.
Abscess may, apart from pyemia, occur in
more than one situation in the brain at the same
time. Thus it has been found simultaneously
in the cerebellum and the temporo-sphenoidal
lobe, in the occipital and the temporo-sphenoidal
OF ABSCESS OF THE BRAIN
133
lobes, and also in the frontal and temporal lobes.
The simultaneous development of abscess in
more than one situation must confuse the symp-
toms and will probably render an exact dia-
gnosis impossible. Unless the abscesses formed
Fig. 54. — Two abscesses in the brain. (Durante, in Chifault, vol. iii.)
Patient, ast. 7 years, suffered from fracture of the right parietal bone. This was
followed by abscess in the temporal lobe which was drained.
Death was caused by abscess of the middle lobe of the cerebellum, and purulent
infection of the ventricles.
one after the other, and the case was most
carefully observed from day to day, successful
treatment would be well nigh hopeless.
Diagnosis of Brain Abscess with Complications.
I. Abscess with meningitis. — The symptoms of
abscess will be modified or controlled by those
of meningitis, according as the abscess or the
134 SOME POINTS IN THE SURGERY
meningitis is the more prominent disease. In
abscess complicated with meningitis the tem-
perature is relatively high, the pulse quick,
delirium, convulsions, and optic neuritis occur
early, pain in the head is severe, and retraction
of the head may be present, together with
vomiting, squint, and irregular respiration.
2. Abscess co?nplicated by pyamia. — The
lateral sinus is often involved in cases of cere-
bellar abscess, the abscess in the cerebellum
being secondary to sloughing of the wall of the
sinus. The symptoms therefore are first those
of pyemia and secondly those of abscess. As
the abscess increases, the mental state becomes
impaired, and the lower temperature and slower
pulse of abscess replace the oscillating tempera-
ture and rapid pulse of pyaemia.
3. Abscess complicated with acute hydrocephalus.
— Acute hydrocephalus is no uncommon com-
plication of cerebellar abscess. If an abscess
burst or leak into one of the ventricles, general
purulent infection of the ependyma occurs.
In one such case a cerebellar abscess was
opened and all went vv^ell for seven days. On
the tenth day after opening the abscess the
following symptoms were observed : temperature
96°, pulse 50, apathy, screaming fits from pain in
the head, dilated and stabile pupils. Acute hydro-
OF ABSCESS OF THE BRAIN 135
cephalus was diagnosed, Keen's tapping of lateral
ventricle carried out, fluid escaped under pressure,
next day remission of all symptoms. Five days
later without warning the following symptoms
appeared : temperature 105, pulse 140, wild de-
lirium, unconsciousness, squint. Acute purulent
infection of the ventricles diagnosed. Diagnosis
confirmed by the escape of bubbles of gas and
purulent cerebro-spinal fluid on withdrawing
the tiny tube that had been left in the descend-
ing cornu. Irrigation of ventricles with saline
solution. The pus of the original brain abscess
had yielded a pure culture of pneumococcus,
therefore antipneumococcic serum was given.
In 36 hours the ventricles contained nothing
but cerebro-spinal fluid. The wounds assumed
the pink colour characteristic of successful anti-
toxin injection and ceased to discharge pus.
Pulse temperature and general condition greatly
improved and consciousness returned. Six days
later patient again became unconscious and
died. At the autopsy a second cerebellar
abscess was found which had not been opened.
Rupture of abscess into the ventricles causes
drowsiness, rapidly deepening into coma, high
fever, and speedy death.
136 SOME POINTS IN THE SURGERY
Diagnosis between Brain Abscess and certain other
conditions.
(a) Tuberculous meningitis and tuberculous tumour.
— The symptoms and duration of tubercul-
ous meningitis vary so greatly that diagnosis
is often difficult, especially in childhood. When
associated with chronic purulent otorrhcea the
disease has been mistaken for brain abscess, and
operative treatment undertaken which, of course,
failed in its object. It is important to remember
how often otitis in children is tuberculous, and
that symptoms of intra-cranial disease, simulat-
ing brain abscess, may arise from the presence of
a tuberculous mass or masses in the brain or from
tuberculous meningitis. The writer has many
times experienced this difficulty in diagnosis.
The cases of tuberculous meningitis in which
suspicion of brain abscess is likely to arise
are those of ear disease with palsy. The
salient features in which a case of tuber-
culous meningitis differs from one of brain
abscess are : the temperature is above normal,
the pulse is 100 or more rapid, optic neuritis is
absent or is a late symptom ; except in certain
acute cases, vomiting is neither so urgent nor so
frequent as in abscess, and the child is apathetic
OF ABSCESS OF THE BRAIN 137
from the onset of illness, or even before illness
is suspected is dull or irritable.
The predominance of certain localising
symptoms in cases of tuberculous meningitis,
especially of hemiplegia, has long been well
known, and before the treatment of brain
abscess by operation as a systematic procedure
came into practice, these symptoms were often
considered in relation to the diagnosis of
meningitis from tumour. Several years ago
I operated upon a case in which right
hemiplegia was associated with left purulent
otorrhoea, under the notion that a temporo-
sphenoidal abscess was present, but the case
proved to have been one of tuberculous
meningitis.
[b) Marantic thrombosis of sinuses. — In young
children intra-cranial thrombosis as a complica-
tion of marasmus is not uncommon. It not
unfrequently causes paralysis, and is sometimes
associated with ear disease.
The main facts which distinguish these
cases from abscess are : (i) The temperature
above normal ; (2) the pulse more rapid ;
(3) the slight degree of ear disease, and (4)
the alternating paralysis of the eyes and face.
{c) Embolism, hcemorrhage, and thrombosis. —
When an elderly patient who happens to have
138 SOME POINTS IN THE SURGERY
a discharge from the ear presents symptoms
of brain lesion we naturally inquire whether
the cerebral condition arose from the ear
disease.
In the aged the temporal bones are sclerosed,
and if tympanic disease arise it cannot produce
an infection of the brain until sufficient time
(months or years) has elapsed for the inflamma-
tory process to pass through the dense boundaries
of the tympanum ; the comparatively rapid
intracranial infection seen in young children
with unclosed sutures and soft bone cannot
occur.
Again, in abscess of the brain due to ear
disease the onset of the brain symptoms is
gradual, and they may not reach their acme for
two or three weeks, while in vascular lesions of
the brain the symptoms may be fully developed
in a few hours or, at most, days. In embolism
the onset is usually instantaneous, and prolonged
unconsciousness is rare. In haemorrhage the
patient may be a sufl^erer from chronic heart or
renal disease ; the onset is usually rapid and
arterial pressure is in excess. In thrombosis
the manifestation of the symptoms is more
gradual and may extend over a few hours
or days.
OF ABSCESS OF THE BRAIN 139
Treatment '
I. General considerations. — An abscess in the
brain should be dealt with surgically on the
same principles as an abscess elsewhere in the
body, viz. by incision so planned as to evacuate
its contents and to provide for free and spon-
taneous drainage, or, in the event of the abscess
being encapsuled, by its complete enucleation.
In operating for brain abscess, however, the
surgeon has to find out as he goes on the size
and exact situation of the abscess, the acuteness
or otherwise of the suppurative process, and even
whether he has to deal with circumscribed or
diffused inflammation or with both, facts which
are readily enough ascertainable by physical
examination with regard to an abscess in an
accessible situation. A case of acute cerebellar
abscess which was opened with relief to the
symptoms, died, and at the necropsy an old
encapsuled abscess was found internal to that
which had been opened.
When the abscess is found and opened, the
brain tissue, which is of liquid texture and
enclosed in an inextensile bony capsule, at once
flows together in obedience to the laws of hydro-
statics, and may shut off a portion of the abscess
cavity from communication with the incision.
I40 SOME POINTS IN THE SURGERY
There is thus a difficulty in maintaining free
drainage. The integrity of certain parts of
the brain is essential to the continuance of life,
and in certain directions a limit is therefore
placed on surgical interference.
These general considerations, though they in
no way modify the principles of treatment of
brain abscess, have an important bearing upon
the details of operation.
2. Operation for brain abscess following local
cranial disease. — It has been already said that in
brain abscess, following frontal or temporal bone
disease, the suppurative process has extended by
direct continuity from the disease in the bone to
the white substance of the brain. The operation
for the evacuation of the abscess should there-
fore be a direct continuation of the operation for
the removal of the disease of the bone.
Every endeavour must be made to discover,
follow out, and remove the pathway traversed
by the infective process through the bone into
the interior of the skull. If, for example, in
the course of a mastoid operation this is not
discovered, and the symptoms point clearly to
the abscess being in the cerebellum or in the
temporo- sphenoidal lobe, the surgeon should
work his way in the one case from the inner or
posterior wall of the antrum to the posterior
OF ABSCESS OF THE BRAIN 141
surface of the petrous, and in the other he should
enter the middle fossa by removing the roof of
the tympanum and attic. So much of the
petrous or squama must be removed as is
necessary to thoroughly expose the extra-dural
abscess or the diseased portion of the dura re-
presenting the point of attachment of the abscess
to the meninges. Thus by the adoption of this
route for the evacuation of the abscess, we
recognise that the abscess is, in most cases, not
an isolated globe within the white substance,
but has a narrow portion or stalk passing
through the cortex and adherent to the dura
at the original site of infection.
This stalk is the track through which the
infection entered. Its lumen presents a ready-
made channel, with fibrous walls through which
drainage can be effected and the infective material
made to leave the brain. This natural tube is
not liable to be obstructed by the flowing
together of the liquid substance of the brain
by which the efficiency of all forms of artificial
drainage tube is so much impaired. If, then,
the abscess can be tapped through the stalk itself
without the knife passing through healthy cortex
and meninges, there would be efficient drainage
without risk of suppurative meningitis or hernia
cerebri.
142 SOME POINTS IN THE SURGERY
11
r
-^y /A
Hi^-i"
T
'" "m
^^^H -"
m
v/^,/^/Ma^H
^^^■i
i
J
Fig. 55.
Fig. 56.
Fig.
Fig. 55. — View from above of portions of the left middle and posterior fossae.
G, eroded edge of tegmen antri ; «, site of tegmen antri destroyed by disease ;
f, trephine opening through which cerebellar abscess (D in Fig. 57) was drained ;
r, tegmen tympani j g, remains of tegmen antri. The tympanum and antrum are
enlarged by erosion. A black style projects through the opening, which leads from
the antrum into the posterior fossa.
Fig. 56. — Sketch of upper surface of cerebellum, showing by a dotted line the
extent of the undrained abscess. * marks the place where the stalk of the undrained
abscess was adherent to inflamed dura at site of carious erosion on posterior surface
of petrous. LL, line of section shown in Fig. 57.
Fig. 57. — Drawing of transverse section of cerebellum, corresponding to line
LL in Fig. 56. The drawing tepresents the posterior part of the specimen seen
from in front. D, track along which one cerebellar abscess was drained through the
trephine opening {t in Fig. 55); MM, amygdalas ; S, undrained abscess. This
abscess measured (see Fig. 56) 53 mm. from side to side, 28 mm. in the antero-
posterior direction, and about 14 mm. from above downwards. After hardening the
depth of the abscess appeared greater than when the specimen was fresh. The
abscess was close to the upper surface of the cerebellum.
OF ABSCESS OF THE BRAIN 143
In a cerebellar abscess the point of attach-
ment of the abscess to the dura is over the sinus
groove, over the aqueductus vestibuli, or over
the internal auditory meatus. In temporo-
sphenoidal abscess the point of attachment is
over the anterior surface of the petrous, and
most commonly to the dura covering the
tegmen. In frontal lobe abscess the point of
attachment is usually on the cranial wall of the
sinus. In deep abscess following injury the
point of attachment of the stalk is in the region
of the fracture.
Drainage through the stalk would, if
successfully accomplished, remove all urgent
symptoms and obviate the tendency to death.
In some cases no doubt such an opening would
not be sufficient to effect a cure, and the surgeon
would be obliged to make a counter-opening, as
he would in other parts of the body. To do
this it is desirable to remove a considerable
area of bone, and then to open the dura and
pack the wound with gauze, so as to get the
area of the brain through which an incision
is to be made isolated by adhesions, on the
principle so long rendered familiar by colotomy
and similar operations. By doing the operation
in this way a new point of attachment of the
abscess to the dura is formed, and the danger of
144 SOME POINTS IN THE SURGERY
diffuse encephalitis avoided. The area of bone
to be removed will be determined by the position
and size of the abscess, as ascertained by a probe
passed through the open stalk.
In some cases when, for example, respiration
Fig. 58. — Frontal lobe abscess secondary to frontal sinus disease.
(Modified from Killian.)
Note the stalk of the abscess springing from the cranial wall of the frontal sinus.
Such an abscess is commonly situated in the white matter of the basal part of the
first frontal convolution. As it extends backwards it tends to involve the corona
radiata and anterior end of the internal capsule, causing paresis of face, tongue, arm,
and leg in the order named on the contralateral side. Killian says, " In a very
instructive' case, in which recovery took place, I was able to observe motor
disturbances arise and completely disappear after the operation."
has ceased, the condition of the patient is so bad
that there is no time to follow a possibly
tortuous route through which the disease found
entrance to the brain. At all costs the abscess
must be evacuated quickly. The abscess must
then be reached by the most direct route and by
OF ABSCESS OF THE BRAIN 145
the most rapid method. Just as in some cases
of intestinal obstruction the bowel must be
emptied without reference to the cause of ob-
\.:..4
Fig. 59. — Abscess of cerebellum occupying the anterior and inner part
of the left hemisphere.
a, abscess ; f, flocculus. The tract through which abscess was opened is visible.
Two bristles pass into the abscess through an opening in the cerebellar cortex opposite
the internal auditory meatus. The day following opening of abscess patient died.
Autopsy. — Pus in labyrinth and internal auditory meatus. Dura adherent,
softened, and perforated opposite internal auditory meatus.
The illustration shows how a cerebellar abscess should not be opened. The direct
route to open the stalk was through the petrous.
struction, so in certain cases of brain abscess the
abscess must be evacuated before dealing with
the local bone disease.
L
146 SOME POINTS IN THE SURGERY
On two occasions in my experience it has
happened that with the first few inhalations
of chloroform respiration ceased, and the opera-
tion had to be completed during the performance
of artificial respiration. In another, artificial
respiration had been in progress two hours before
I arrived. Neither morphia nor strychnia
Fig. 60. — Drawing to show the direction in which the complete mastoid operation
should be extended in order to drain a cerebellar abscess through its stalk.
The oval marked by a black line indicates the region between the sigmoid sinus
behind and the facial canal in front, where bone may be safely removed. Working
cautiously inwards with burr or gouge, the operator will come upon the stalk of a
cerebellar abscess attached to the dura, on the inner side of the sinus, or anywhere on
the posterior surface of the petrous as far inwards as the internal auditory meatus.
The operation is easier when there is a visible carious track.
should be administered before the dura has been
opened.
3. Discovery atjd incision of the abscess. — The
abscess may burst as the dura is opened. When
there is a sufficient opening in the bone and dura
it may be possible to determine by palpation
that the abscess is immediately sub-cortical. An
incision should then at once be made through
OF ABSCESS OF THE BRAIN 147
the intervening portion of brain substance into
Fig. 61. — Coronal section of left cerebral hemisphere from a man, aged 29, displaying
a small temporo-sphenoidal abscess 1 cm. in diameter, situated just above the
tegmen tympani. The abscess was secondary to chronic otitis media. The
rod lodged in the brain above the abscess shows the track made by the trocar
at the operation performed for the relief of the disease. This track just misses
the abscess cavity. The patient died of meningitis. (Norwich Hospital
Museum.)
Remarks. — Compare with Fig. 59. The illustration shows how a temporo-
sphenoidal abscess should not be opened. The direct route to open the stalk
(attached to the tegmen) is through the tegmen.
the abscess cavity, care being taken to avoid
148 SOME POINTS IN THE SURGERY
wounding the vessels, as in other parts of the
body. The use of a trocar and cannula, pus-
seeker, or other special instrument is unnecessary.
If the site of the abscess is not obvious it must
be sought for by exploratory puncture, and in
so doing it should be remembered that the site
of the abscess is almost certainly close to the
bone disease which gave rise to it. The best
instrument to use is a sharp-pointed, long, and
narrow knife. Our brains are not like Satan's —
Entrails, heart or head, liver or reins —
which Milton tells us could
Not in their liquid texture mortal wound
Receive, no more than can the fluid air ;
and a wound made by the surgeon's knife will
not heal quite so readily as that inflicted by the
sword of Michael ; yet in the brain, as else-
where, clean cut wounds heal more readily than
any others, and there is certainly less risk of
missing an abscess with the knife than with any
other instrument.
There have been cases in which the trocar
and cannula has — i. Missed the abscess. 2.
Passed through it without tapping it. 3. Struck
the capsule but failed to penetrate it.
The use of the knife for the evacuation of
an abscess of the brain is not a new operation,
1
OF ABSCESS OF THE BRAIN 149
but was taught and practised more than a
century ago. Dupuytren in one of his lectures
says : —
"In certain cases of deeply - seated fluid
collections we must incise the dura mater, the
arachnoid, the brain itself, if the focus is at
the surface of this organ, and by this bold pro-
ceeding patients have been saved."
And a little further on in the same lecture
he continues : —
" Relying also on the success of J. L. Petit,
Boyer concurs in the advice of Quesnay, and
does not fear to plunge the bistoury quite
deeply (assez profondemeni) into the very sub-
stance of the brain in order to evacuate traumatic
effusions which may have formed there, and it
has fallen to my lot to do so several times
with success." Like many another step in the
advance of knowledge, this advice, though
justified by some brilliant successes, remained
for a considerable time a dead letter, for we
find a great English surgeon writing nearly
half a century later : " There are few surgeons
who would have the hardihood of Dupuytren,
who plunged a bistoury into the substance of
the brain and thus luckily relieved the patient
of an abscess in this situation." Dupuytren, in
his account of this historical case, says simply :
150 SOME POINTS IN THE SURGERY
" I incised the dura mater, nothing came out ;
I thrust a bistoury cautiously " (? so as to avoid
the vessels of the cortex) " into the brain and
there welled up immediately a flood of pus.
That very night all the symptoms disappeared
and the patient recovered."
If careful exploratory puncture with the
knife fail to find the abscess, the finger inserted
into the brain substance will almost infallibly
detect the presence of a tense, abnormal swelling,
and however deep the abscess is it may be safely
opened by the knife guarded by the finger.
Mistakes, however, may still be made, as in
two cases I treated many years ago. In one
of these one cerebellar abscess and in the
other two had been opened, yet both patients
died from an unopened abscess, oyster- like in
shape, lying immediately beneath the cortex of
the upper surface of the cerebellar hemisphere.
The examining finger felt the sensation of
resistance, but this was attributed to the
tentorium.
The stalks of these abscesses would probably
have been found and their contents evacuated
had they been approached by way of the disease
in the temporal bone.
OF ABSCESS OF THE BRAIN 151
Progress of the Case.
The course of brain abscess is, as I have
shown, very variable.
The earlier the operation is carried out the
greater the chance of success, hence the condition
having once been diagnosed action should never
be delayed.
I have known of cases where operation has
been arranged for the following morning, but
the patient died in the night.
Unless the patient is actually moribund the
operation should be done. Even cessation of
respiration is no bar to success in cases of brain
abscess, for the operation has been carried out
during the performance of artificial respiration
and the patient has recovered.
After the operation the patient may rapidly
convalesce or may present symptoms which will
tax to the utmost the resources of the surgeon.
A voracious appetite is a favourable sign.
Just as symptoms may arise after an operation
for appendicitis which give rise to anxiety lest
the infective process should still be in progress,
but which are merely due to temporary paralysis
of the gut or to some other manifestation of the
functional disturbance of the abdominal contents
caused by the disease or the operation ; so after
152 SOME POINTS IN THE SURGERY
an operation for the relief of an intra- cranial
infection, symptoms such as vomiting, fever, and
delirium may continue or newly arise during
convalescence and give rise to similar anxiety,
but may nevertheless be likewise due merely to
disturbance of cerebral function and not call for
operation. Apart from this, however, it is by
no means uncommon to have definite recurrence
of symptoms a few days after the evacuation of
an abscess of the brain, due either to the re-
filling of the abscess cavity from faulty drainage
or to the formation of a new abscess in another
part of the same lobe. The new symptoms are
much modified by the skull being opened, and
may suggest conditions, such as meningitis or
acute distension of the ventricles, which are not
present. The surgeon must not suflfer himself
to be led astray by idle speculations as to the
explanation of the symptoms, but must con-
centrate his attention on the region where he
has already found abscess, and whatever the
symptoms may be must explore the same region
of the brain.
During apparent convalescence some cases of
brain abscess begin to retrograde without evident
reason, and finally end fatally. A similar event
occurs occasionally after the removal of large
brain tumours, and depends on a general
OF ABSCESS OF THE BRAIN 153
nutritional failure. In these cases large areas
of brain are involved, and the healing process
exhausts the vitality of the patient.
In my surgical life the evolution of the
operation for brain abscess has advanced a good
stage towards perfection. Not many years ago
but few surgeons had even made any attempt
to operate for brain abscess ; but at the present
time in every surgical clinic such operations
have been performed.
Although we are at present only on the
threshold of a perfect understanding of the
surgical treatment of abscess of the brain, yet
the labour of many workers during the last
twenty years has not been in vain, and the
future is bright with promise.
REFERENCES.
Bristowe. British Medical Journal, I 89 1.
Claytor. Philadelphia Medical Journal, March 2, 1901.
Stoll. American Journal of the Medical Sciences, Feb. 1906.
Blottche. Quoted from Stoll.
Cayley. Pathological Society's Transactions, vol. xxxv. (1883),
p. 12.
Pye-Smith. Pathological Society's Transactions, vol. xxviii. ( i 876),
p. 4.
Rudolph Meyer. Zur Pathologie des Hirnabscess, 1867.
Newton Pitt. British Medical Journal, 1890.
Preysing. Zeitschrift fur Ohrenheilkunde, vol. xxxv. p. 108, and
vol. xxxvii. p. 208.
Salzer. Weiner klinische Wochenschrift. Band iii. No. 34,
Manasse. Zeits. f. Ohrenheilk., vol. xxxi. p. 226.
Swain. Zeits. f. Ohrenheilk., vol. xxxi. p. 351.
154 SOME POINTS IN THE SURGERY
Bf.rgmann. Die Chirurgische Behandlung von Hirnkrankheiten.
Third edition.
KuMMEL. Zeits. f. Ohrenheilk., vol. xxviii. p. 259.
RoNCALi. In Chipault, Ltat actuel de la Chirurgie nerveuse,
vol. iii.
Jackson and Beevor. Brain, 1887.
Ferrier. The Functions of the Brain.
Mills. Article in Dercum's Text-Book of Nervous Diseases and
other papers. Broadbent, Charcot, Ross, Bastian, quoted from
Mills.
Preysing. Archiv f. Ohrenheilk., vol. li. p. 266.
Brissaud and Souques. In Traite de medecine, Charcot-Brissaud.
Second edition, vol. ix.
Piorry. Traite de diagnostic (1838), vol. iii. p. 294.
Beevor and Jackson. Loc. cit.
RoNCALi. Loc. cit.
Brissaud and Souques. Opus cit.
Okada. Diagnose und Chirurgie des Otogenen Kleinhirnabscess.
Paradise Lost. Book vi., line 346.
DupuYTREN. Lefons Orales. Second edition, vol. vi. pp. 183-84.
Erichsen. The Science and Art of Surgery. Seventh edition,
(1887), vol. i.
Stephen Paget. Clin. Soc. Trans., vol. xxx., " On Cases of
voracious Hunger and Thirst from Injury or Disease of the
Brain." The suggestion is made that there are special centres
in the brain for the perception of hunger and thirst, situated
near the olfactory centres.
Note to page 112.
I have recently had another case illustrating anomia.
J. B., aged thirty-four, was admitted to the National Hospital
under Dr. Beevor. He had had discharge from the left ear ever
since he could remember. Last January the mastoid operation was
done at a throat hospital in London, but the otorrhcea was not
arrested.
On admission to National Hospital in August there was discharge
of thin pus from the left ear, double optic neuritis, and occasional
pain in left mastoid and temporal regions.
Operation. — Tegmen carious. This was removed, and the dura
above it was then seen to be inflamed.
OF ABSCESS OF THE BRAIN 155
A few days later dura gave way, and a hernia cerebri formed. I
then discovered that the patient could not name any object such as
a watch, scissors, or pencil, though fully understanding what they
were. Two days later patient became drowsy, and a small abscess
of thin pus was evacuated by passing a knife up through the opening
in the dura through which the hernia protruded. A few days later
the patient died.
Autopsy. — Spreading septic process without boundary wall involv-
ing second and third temporo-sphenoidal convolutions, and adjoin-
ing tempore -occipital convolution. The tip of the temporo-
sphenoidal lobe and the first temporo-sphenoidal convolution were
not involved. There was also meningitis diffused over the base of
the brain, not over the vertex.
Remarks. — Patient probably entered the hospital with commen-
cing infection of the temporal lobe. It would have been perhaps
better if I had incised the dura in the first instance, but spreading
septic cerebritis is always a very fatal disease.
LECTURE III
SOME POINTS IN THE SURGERY OF TUMOUR
OF THE BRAIN
Diagnosis — Difficulty of localisation — Symptom complex — Absence
of all symptoms — Localisation symptoms — Relation of injury
to tumour growth — Tumours of the cranium, the meninges,
and the brain — Tubercular and syphilitic tumours — Endo-
thelioma— Fibro-sarcoma — Glioma, solid and cystic — Sarcoma
— Psammoma — Cysts — Secondary tumours — Treatment with-
out operation — Operations, curative and palliative — Pioneer
work of the past, the present position, and future outlook.
I APPEAR before the Society this evening to
speak of the surgery of tumours of the brain
not as an apologist but as a modest exponent of
a splendid and established department of general
surgery. It would be impossible in the course
of a single hour to give any adequate account of
so vast a subject as that of intra-cranial tumours.
I shall attempt no such task, but shall only
endeavour, in a somewhat elementary manner,
to draw your attention to the resources which
surgery offers for the relief or cure of these
terrible cases. Not many years ago very few felt
156
TUMOUR OF THE BRAIN 157
any enthusiasm for the surgery of the central
nervous system, and our early efforts were received
by the majority with, at best, friendly scepticism.
Even now the advance made in this depart-
ment of surgery has received less recognition
than it deserves, and one reason that influenced
me in choosing this subject was that it would
enable me to review my personal experience
and perhaps to arouse in others an interest as
yet latent.
In a monograph on the subject published
last year the results of 400 operations for brain
tumour are discussed. In a large proportion
notable improvement or cure resulted, and in
some instances even recurrent growth was
successfully dealt with. Still more recently an
American surgeon has analysed the results of
116 operations for tumour of the cerebellum
alone.
Some twelve years ago, in conjunction with
my friend and colleague Dr. Beevor, I brought
, before this Society a successful case of operation
for brain tumour. We expressed the conviction
that in a few cases of brain tumour the growth
could be extirpated and the patient definitively
cured, in others partial removal would give
material relief and prolong life, and in yet
others, though the tumour itself had to be left
158 SOME POINTS IN THE SURGERY
untouched, the relief of intra- cranial pressure
by opening the dura would so modify the
symptoms as to restore the patient to com-
parative comfort.
I shall not discuss the etiology or the morbid
anatomy of brain tumours. I have elsewhere
expressed my opinion as to the aetiology of
tumours in general, and that of brain tumours
does not differ therefrom. Certain histological
varieties of tumour are peculiar to the brain,
otherwise the morbid anatomy of brain tumours
is that of tumours elsewhere.
In this connection I use the word tumour
in a wide sense as including cysts, and the
products of the infective granulomata as well
as neoplasms proper, inasmuch as clinically and
surgically they are all " tumours."
The following is a list of cerebral tumours
the majority of which are of surgical im-
portance : —
Intra-Cranial Tumours.
I. Epiblasdc tumours —
A. Cerebroma,
B. Glioma, glio-sarcoma, angio-glioma.
C. Epithelioma. Developed from the epi-
thelium of the ependyma, the choroid
plexus, the pineal gland, or the pituitary
body.
D. Cholesteatoma vera.
OF TUMOUR OF THE BRAIN 159
II. Mesoblastic tumours —
A. Sarcoma ; of skull, of meninges, of brain
substance (probably arising from the
walls of the intracerebral vessels), of
the pineal gland, of the pituitary body.
B. Endothelioma ; meningeal. (The fibro-
plastic tumour of Lebert.)
C. Fibroma. Fibro-sarcoma.
D. Psammoma. Angio-lithic sarcoma.
III. Secondary tumours : metastases from carcinoma
or sarcoma of other regions.
IV. Cysts. — Simple cysts. Hasmorrhagic cysts.
Parasitic cysts. Intra- and extra-dural
dermoids.
V. Tuberculous tumours.
VI. Gummata.
VII. Vascular tumours. — Aneurism.
:/' -.-
Fig. 62. — Glioma of frontal lobe. (R. C. S. Museum,
52, A.
A section through the right hemisphere, showing a large rounded glioma, 3
inches in diameter, which occupies the whole of the frontal lobe. Anteriorly and
above, the tumour projects upon the free surface ; below, it is bounded by a thin
band of brain substance. Its margin is well defined ; its section is homogeneous
and in parts flocculent. From a man, aged 25, who had been for a long time under
treatment with double optic neuritis, occasional convulsions, and paresis on one side.
An attempt was made, but failed, to get at the tumour to enucleate it. (Presented
by Dr. Goodhart, 1885.)
i6o SOME POINTS IN THE SURGERY
Fig. 63.
-Cholesteatoma vera of cerebellum. (R. C. S. Museum, 3779 B.
Presented by Miss Knowles.)
A cerebellum, between the lateral hemispheres of which there projects a large
cholesteatoma, which has grown from the situation of the fourth ventricle. The
tumour has an extreme diameter of about two inches, is of irregularly spheroidal
form, in places mammillated, and presents throughout the pearly lustre characteristic
of this class of new growth.
The patient, a well-developed woman of 30, complained of pains in the back of
the head " like knives " ; a feeling of weight on the top of the head j of a sensation
of "pins and needles" in the hands and feet; and of inability to walk. She had
enjoyed good health until two years ago, when she was noticed to stagger in
walking ; the difficulty in locomotion increased steadily, and of late she had been
constantly falling. The pains in the head and the other subjective sensations were
of only three weeks' duration. No history of syphilis, otitis, injury to the head, or
alcoholism could be obtained. On admission she was a well-nourished woman, of
medium height and sallow complexion ; her mental state was dull, and she was
slow in answering questions, but did so correctly. Speech was thick and indistinct,
resembling that of a general paralytic. The tongue was protruded in the middle
line, and was distinctly tremulous. The breath was offensive. The gait was a
staggering one with the feet wide apart, and the arms extended to preserve the
balance. There was a constant tendency to fall to the left, and Romberg's
symptom was well marked. The muscular power in both lower limbs was good ;
no tenderness on pressure, no rigidity, muscular wasting, or anaesthesia could be
detected. The knee-jerks were present on both sides, but exaggerated; ankle
clonus was not obtained. In the upper limbs the only thing noted amiss was a
slight impediment of muscular sense. As regards the head, there was slight but
distinct tenderness to percussion and pressure over the whole of the occipital region,
but it was not more marked on one side than on the other ; there was no facial
or ocular paralysis, and no nystagmus. Pupils equal, moderately dilated, reacting
readily to light and accommodation.
The bladder acted normally ; the bowels were obstinately constipated. The
patient lay quietly in bed and slept well at night ; she complained of moderately
severe occipital headache ; there was no vomiting ; the appetite was good, and the
temperature varied between 97°.4 and 99°. 2. Pulse normal. On September 24,
five days after admission, she became restless, attempting to get out of bed : at
intervals she would lie quietly curled up on the left side. Towards evening the
pulse became very rapid, respiration failed rather suddenly, and she died, remaining
conscious almost to the last.
OF TUMOUR OF THE BRAIN i6i
Fig. 64. — Endothelioma of meninges of temporal lobe. (Dupre and Devaux.)
Male, aged 34 years. History extending over 2-5 years.
The symptoms observed were headache, vomiting, vertigo, troubles of memory,
mental dulness, progressive blindness from optic neuritis and atrophy ; then epilepsy,
slight local paresis, dementia, coma, and death. Large circumscribed, spheroidal
tumour, size of an orange at the base of the left hemisphere, compressing the orbital
lobe, the insula, and the tip of the temporo-sphenoidal lobe. An endothelioma of
the arachnoid.
Fig.
65. — Carcinomatous deposit in centrum ovale, secondary to growth
oesophagus. (Norfolk and Norwich Hospital Museum, No. 170.)
P. L., aged 50. Male.
Admitted September 8, 1900, complaining of loss of power in left arm, which
came on after two recent fits, one three weeks ago, and the other two weeks ago.
M
1 62 SOME POINTS IN THE SURGERY
When admitted he had complete paralysis of left arm, none in leg. Hard, irregular
tumour in epigastrium.
October 9. — Convulsions of left arm, double optic neuritis, proptosis of left eyeball.
,, 18. — Another fit of same character to-day, with no loss of consciousness.
The fits continued up to October 30, when he died j the left arm gradually became
contracted and rigid, and some contraction also developed in the left leg.
P.M. — Hard, carcinomatous growth, size of a fist, at the lower end of the
oesophagus. Many growths throughout lungs and in liver.
Large lumour under Rolandic area and right half of brain, extending almost from
the frontal to the occipital lobe.
Fig. 66. — Carcinomatous deposit in the skull secondary to Scirrhus mammae.
E. A. S., aged 70 years.
April 1904. — Removal of left mamma and axilla by Halsted's method for
spheroidal celled carcinoma.
August 1906. — -Above photograph taken. Tumour had been noticed three months
before. There was no pain, no tenderness on pressure, and no cerebral symptoms.
Patient otherwise well ; region of primary operation healthy.
OF TUMOUR OF THE BRAIN 163
Fig. 67. — Sarcoma of brain (multiple growths), secondary to sarcoma of lung.
(Norfolk and Norwich Hospital Museum, No. i66. A.)
S. M., aged 24. Male.
Admitted August 7, 1902.
Quite well on August 3. Cough and expectoration began on August 4.
August 9. — Three fits, beginning in right arm. Fits occurred almost every day
for two months, sometimes five or six in one day ; often confined to right hand.
At the end of the two months patient had distinct hemiparesis, but could walk
about, dragging right foot.
No'vember 13. — -The fits have continued in lessening number since last note;
purulent expectoration, double optic neuritis.
No'vember 25. — Left motor area exposed, and soft, non-encapsulated growth scooped
out.
December 8. — Much purulent expectoration ; power in right arm increased con-
siderably as result of operation.
December 13. — Fits recommenced.
January to March 1903. — Much vomiting and headache ; large hernia cerebri.
Died March 8, 1903.
P.M. — Large new growth in lung. Multiple secondary growths in brain.
The microscopical section shows the cells arranged in groups around the blood-
vessels. The cells are mostly round ; some are oval and spindle-shaped.
1 64 SOME POINTS IN THE SURGERY
Fig.
i. — Simple cyst of right cerebellar hemisphere. (St. Thomas's Hospital
Museum, Path. Series, Part iii. 2013.)
From a girl, aged 14., admitted under the care of Dr. Bristowe, November 4, 1887.
Three months before her admission her sight began to fail, strabismus and double
vision being observed ; in a few weeks vomiting and headache came on, but during
all the time there had been no giddiness and no fits.
On admission there was severe double optic neuritis, and sight was much impaired,
the left eye having no perception of light ; convergent strabismus of the left eyeball.
Hearing was impaired on the left side. There was no paralysis or staggering, and
no loss of sensation. During the five months she was under observation in the
hospital there were frequent attacks of headache and vomiting. Six weeks after
admission she was blind, and the optic discs were becoming atrophied. During the
last three months there were rather frequent fits, during which consciousness was
lost, the head thrown back, the eyes fixed, and the extremities rigid. (Dr. Hadden,
Fat/i. Soc. Trans., vol. xli. p. 17.)
OF TUMOUR OF THE BRAIN 165
Fig. 69. — Simple cyst of right cerebellar hemisphere. (St. Thomas's Hospital
Museum, Path. Series, Part iii. 2012.)
J. T., aged 22, admitted under Dr. Stone, October 15, 1878. From the age of
twelve years he had been frequently attacked with severe headache, not localised to
any particular region. For the three or four past years he had noticed some loss of
power in the right upper and lower extremities. About four months before admission
the patient was struck on the back of the head by two heavy shutters, and since then
he has not been free from headache ; about a week or two later vomiting became a
pretty frequent occurrence, and did not seem to have any relation to taking food 5
his sight became dim, and shortly before entering the hospital he had some kind of
convulsive attack. Marked optic neuritis was found by Mr. Nettleship. On
November 4 he had a fit of fainting, with severe headache and rigor, vomiting and
retching. On November 5 the report states that he had had many severe rigors,
unaccompanied with rise in temperature. He was suddenly attacked with stertorous
breathing, became comatose, and died in ten minutes.
Autopsy. — Except for the cyst of the cerebellum shown, the rest of the brain
appeared normal, and there was no important disease of any of the other organs.
Microscopic examination showed no cyst wall apart from the condensed tissue of the
cerebellum. There was no evidence anywhere of haematoidin crystals or granules.
i66 SOME POINTS IN THE SURGERY
Fig. 70. — Hydatid of right frontal lobe. (Herrera Vegas, Clitpault, iii.)
Boy, aged 14 years. Operation. Recovery.
Recurrence one year later. Operation. Death.
Fig. 71. — Hydatid of right lateral ventricle removed through post-Rolandic
region. (Herrera Vegas, Chipault. iii.)
Boy, aged 8 years. Headache ; vomiting ; left hemiplegia.
Operation. Cyst size of fcetal head enucleated.
Death on third day.
OF TUMOUR OF THE BRAIN 167
Fig. 72. — Aneurism of the intra-cranial portion of the left internal carotid artery.
(R. C. S. Museum, 3795 D. Presented by C. F. Beadles.)
The anterior portion of the left hemisphere of a brain. In connection with the
left internal carotid artery, immediately on its entry within the cranial cavity, there
has formed a somewhat bilobed aneurism about an inch and a half in chief
diameter ; the sac is mostly filled with firm laminated clot, but through the centre
of this is a narrow cleft which held recent coagulum and fluid blood. A piece of
glass has been passed from the divided end of the internal carotid, artery (which is
cut across close to the sac) into the aneurism, between the wall and the clot.
Another rod of glass has been passed from the same divided end of the artery,
behind the sac, along the anterior cerebral, and out by the anterior communicating,
which vessels lie on the superior aspect of the aneurism. The aneurism is im-
bedded chiefly in the under part of the left frontal lobe, but it also compressed ,the
frontal lobe of the right side ; posteriorly it extends over the infundibular space j the
roots of the olfactory and optic nerves were seriously damaged. Blood was found
extravasated into the pia-arachnoid, between the frontal lobes and the sac ; the
source of this blood, which has been removed, was apparently the left anterior
cerebral artery. The other cerebral arteries appeared healthy. The kidneys were
reduced in size and granular.
From a female, aged 48, who died August 13, 1902. She was the subject of
aural hallucinations, optical delusions, and delusions of electrical annoyance, and had
been violent towards her relatives. She was melancholic.
On February 19, 1897, she is said to have complained of "a hissing noise in her
head, which she thinks due to electricity " ; she complained of a voice continuallv
annoying her. Outward divergence of the right eyeball was present, and there was
a very slight tendency to paresis of the right side of the face.
On April 2, 1898, she was in a depressed mental state. She complained that
" when she sneezes under the bedclothes she sees the bronze flash from her eyes j
says she is being bronzed, and that electricity is applied to her." The condition of
the eye was much the same, but the facial paresis had slightly advanced. For two
years or more there was little change in her condition. The aural hallucinations
and optical delusions persisted ; she heard men under the floor, who applied
electricity to her 5 she saw "spirits flying about," which gave her great annoyance,
and which occasionally made her excited. She would suddenly stamp on the floor
and throw things at the spectre, but generally she was inclined to be melancholic.
Her hearing remained good, and there was never any indication of defect of sight ;
she did needlework almost up to the last. During the last year of life the right
eyeball became more markedly turned outwards. There was never any form of fit
or seizure. Speech was unaffected, and she was always fairly coherent. There
was occasional vomiting, unassociated with food, during the last few months. She
never complained of pain in the head, and there was never any attack of giddiness.
She gradually lost flesh, and although looking ill, never spoke of feeling so.
On August 9, 1902, she had a sudden apoplectic seizure, and remained in a
comatose state for four days, and then died.
i68 SOME POINTS IN THE SURGERY
Operations
I propose to bring before you examples of
the various operations that may with advantage
be performed and thereby to attempt an answer
to the question, " What do patients suffering
from tumour of the brain gain from surgery ? "
1. In the first place a well-defined and
accessible tumour such as fibroma or endo-
thelioma of the meninges can, and should, be
completely removed. No time need be spent
in arguing the value of such an operation.
2. Local solitary manifestations of tubercle
and sometimes of syphilis should be removed.
An excellent example of removal of a syphilitic
tumour is published by Bardesco. The patient
was a man thirty-six years of age and had hemi-
plegia, from which he completely recovered. A
successful case of removal of a gumma of the
left cerebellar hemisphere by Horsley is pub-
lished in Brain^ vol. cviii.
3. Infiltrating growths, such as glioma and
sarcoma of the brain, can but seldom be com-
pletely removed, chiefly because in the. living
brain there is often no visible and obvious line
of demarcation between the brain and the
tumour tissue. The gain after partial removal
is that the tumour grows more slowly. The
OF TUMOUR OF THE BRAIN 169
partial removal of a malignant tumour of another
part of the body, say the mamma, is followed by
continued or even more rapid growth, but the
partial removal of a malignant tumour of the
brain appears in some instances to have a
contrary effect. This probably results from the
profoundly altered physical conditions being less
favourable to the local absorption of toxin and
to the growth of the essential elements of the
tumour. An operation which would deprive the
patient of the power of speech is not justifiable.
4. Cysts, simple, hydatid, or malignant, should
be dealt with by drainage or by ablation, according
to circumstances. Herrera Vegas of Buenos Ayres
has operated successfully for hydatid cysts, and
MacHill of Melbourne has collected thirteen cases
of operation for hydatid of brain performed in the
Australian colonies, in six of which complete cure
resulted. The same author refers to five cases in
which operation had been decided upon but the
patient died before the date that had been fixed
for it. In hydatid of the brain, as in abscess,
sudden aggravation of symptoms is liable to
occur and no delay is permissible when once the
diagnosis has been made.
Many cases of operation for hydatid of the
brain have died from early hyperpyrexia. Bird
of Melbourne states that this is due to hasmor-
lyo SOME POINTS IN THE SURGERY
rhage into the cavity left by the operation, and
to prevent this result he has successfully practised
filling the cavity left by the operation with gauze
and allowing this to remain in place for six days.
I have never operated for hydatid of the brain,
but I have successfully done so for hydatids of
the spinal canal causing paraplegia.
5. When the tumour cannot be localised, or
is too deeply placed for removal, the skull and
dura should be opened so as to relieve the intra-
cranial tension. No patient should be allowed
to become blind from optic neuritis.
A woman, aged forty-one years, was admitted to the
National Hospital, under Dr. Buzzard, with symptoms
pointing to tumour pressing on the internal capsule :
hemianassthesia, hemiplegia, severe headache, and failing
sight from optic neuritis. She became comatose after
a paroxysm of pain. I opened the skull and dura.
Consciousness returned, and the headache, optic neuritis,
and vomiting were completely relieved. There was
even, a month later, some return of power and sensation
in the paralysed limbs.
Again, a man of forty was admitted to the National
Hospital, under Dr. Buzzard, with agonising headache,
vomiting, and intense optic neuritis. For certain
reasons the tumour was located in the left cerebellar
hemisphere. I removed the bone and dura over this
region, but found no tumour. The man recovered and
returned to work. He died eighteen months later,
when a large tumour was found in the right frontal
region.
OF TUMOUR OF THE BRAIN 171
Fig.
Fig. 76.
Figs. 73, 74, 75, and 76. — The establishment of a cerebral hernia as a decompressive
measure for inaccessible brain tumours. (Harvey Gushing.)
Fig. 73. — Male, aged 32, one month after decompressive operation over left
occipital lobe.
Fig. 74. — Size and condition of hernia one year after the first operation.
Fig. 75. — Drawing of section of brain which passed nearly through the centre
of the tumour, which was a glioma. Note the deflection of the ventricle toward
the hernia. The tumour occupied in large part the entire site of the occipital lobe.
Fig. 76. — Sketch of the field of operation before opening the dura, in the sub-
occipital procedure. Note the high transverse cut of the " crossbow " incision.
172 SOME POINTS IN THE SURGERY
The patient (Figs. 73, 74, 75) had suffered from headache for two years. On
admission to hospital the headache was very severe, with mental dulness, intense
double optic neuritis, projectile vomiting, tenderness over left occipital region, and
some weakness of right face and arm. There was also complete right homonymous
hemianopsia. The operation was not done by the intermuscular method, hence the
large size of the hernia. " An intermuscular operation would probably have left the
patient without his disabling astereognosis, and so capable of working, and at the
same time able to amuse himself with reading, a resource from which he was
entirely cut off." It is not clear why an attempt was not made to remove this
occipital tumour. Gushing gives an admirable example of an intermuscular decom-
pressive operation in a case of sarcoma of the optic thalamus. It was from the
desire to control these formidable hernias that he hit on the plan of making the bone
defect under the temporal muscle. He has carried out the same plan with success
in the cerebellar region by making a " crossbow " incision : the transverse cut is
high above the attachment of the muscles of the neck, which are subsequently
sutured in layers. Gushing, in this paper, relates cases in which Nature
carried out the decompressive operation in early life by separation of the cranial
sutures. " There is a curious reluctance on the part of many surgeons to leave bone
defects in the skull. Emphasis must be laid on the fact that in cases of brain
tumour the defect is desirable. Owing to the inelasticity of the dura the removal of
bone alone does not answer as a palliative measure. The hernia should be established
over as ' silent ' an area of the cortex as possible." There is no doubt in my mind
that the dura must be reflected or removed in decompressive operations. The
removal of even a large area of bone alters very little the volume of the intradural
space. In an experiment performed with Prof. Sherrington many years ago, it was
found (in the case of a recently-killed large dog) that only 0.54 ccm. of fluid entered
the dural cavity in consequence of the removal of half the vault of the skull.
Fig. 77. — Exposure of cerebellum (R. hemisphere) by the usual method.
(From a drawing of an operation by the author.)
The opening is made behind the vertical and below the horizontal parts of the
sigmoid sinus.
Gontrast with Harvey Cushing's " intermuscular method."
OF TUMOUR OF THE BRAIN 173
Symptoms and Diagnosis
The problem presented to the surgeon when
asked to see a case of suspected cerebral tumour
is three-fold.
1. Is there an intra-cranial tumour ?
2. If so, where is it ?
3. What is its nature ?
To the first question an answer can often with
confidence be given, to the second much less
frequently, and to the third rarely. In other
words, we may usually be sure that a tumour is
present, but its exact localisation often presents
a perplexing, and possibly at the present time
insolvable problem. The diagnosis depends
mainly upon a correct interpretation of the
symptoms presented ; radiography, lumbar
puncture, and percussion and auscultation of the
cranium in some cases afford material assistance.
A complete exposition of the symptoms of
cerebral tumour would entail a discussion of all
that is known of cerebral function and its dis-
turbance by disease. Only the general outline
of the interpretation of symptoms can be given
on this occasion.
In the first place we find that intra-cranial
tumours give rise to a group of general cerebral
symptoms, which are quite independent of the
174 SOME POINTS IN THE SURGERY
seat or nature of the growth or of any particular
lesion of the brain ; these symptoms are produced
by-
(a) Alteration of the intra-cranial tension.
(b) CEdema, inflammation, or irritation.
{c) Toxin absorption.
Headache, vomiting, and optic neuritis are
the three main symptoms of this group ; " fits,"
slow cerebration, vertigo, alterations of pulse and
respiration are symptoms frequently associated
with them. These symptoms may occur singly
or in various combinations and in varying degrees
of intensity, and may be regarded as the clinical
expression of the influence exerted upon the
brain as a whole by the intra-cranial growth.
In the second place, symptoms are produced
which depend upon irritation or suppression of
function of nervous centres, or interruption of
commissural fibres connecting various centres
with each other or with organs of sensation or
motion.
These symptoms may be classified in ten
groups : —
I. Mental phenomena. 2. Motor phenomena.
3. Oculo-motor phenomena. 4. Disturbances of
associated movements. 5. Disturbances of equi-
librium. 6. Speech aff^ections. 7. Abnormal
sensory phenomena. 8. Alteration of reflexes.
OF TUMOUR OF THE BRAIN 175
9. Special sense affections. 10. Modifications of
the general functions : circulation, respiration,
secretion.
Guthrie, in 1841, in the opening paragraph
of his well-known lectures, said, " It may even
be said that there is no one symptom which
is presumed to demonstrate a particular lesion
of the brain, which has not been shown to have
taken place in another of a different kind.
Examination after death has often proved the
existence of a most serious injury which had
not been suspected ; and death has not in-
frequently ensued immediately, or shortly, after
the most marked and alarming symptoms without
any adequate cause for the event being discovered
on dissection. Such are the deficiencies in our
knowledge of the complicated functions of the
brain, that although we can occasionally point
out where the derangement of structure will
be found, which has given rise to a particular
symptom during life, the very next case may
possibly show an apparently sound structure
with the same derangement of function."
What Guthrie said of injury is, despite the
advance made since his time, still true of cerebral
tumour. The most eminent neurologists will
occasionally differ as to the localisation of a
brain tumour. In the fable men differed as to
1/6 SOME POINTS IN THE SURGERY
the colour of the chameleon, and all proved to be
right ; but in the localisation of a brain tumour,
if observers differ, only one can be right and all
may be wrong, and further, as I shall point out
later on, there may be no brain tumour revealed
either at operation or autopsy.
Are there, then, any symptoms which de-
finitely indicate the position or even the existence
of a tumour ? No one symptom alone will give
us this information, but the association of certain
symptoms do afford us, if not the certainty, at
least a strong probability of the existence of this
particular lesion. Neither headache, vomiting,
optic neuritis, fits, vertigo, nor hemianopsia alone
warrant the diagnosis of cerebral tumour ;
but two or more of these symptoms in com-
bination do constitute evidence of the existence
of a brain tumour.
For example : —
I . Optic neuritis and headache : in the absence
of anaemia and albuminuria. 2. Fits followed
by paralysis or fits commencing with an aura and
involving successively the various segments of
one or both limbs in a regular order correspond-
ing to the topography of the motor cortex. 3.
Optic neuritis and unsteady gait. 4. Hemi-
anopsia and optic neuritis. It is impossible to
exaggerate the importance of the presence of
OF TUMOUR OF THE BRAIN 177
optic neuritis. The absence of this sign may
make diagnosis impossible, while its presence
may clench the diagnosis. The time and manner
of evolution of symptoms are of equally great
diagnostic importance, as also the absence of
certain symptoms.
The clinical evolution of cerebral tumour
varies greatly : there may be complete latency
of all symptoms, and the tumour remain un-
suspected until the autopsy, the patient either
dying suddenly apparently from the tumour, or
from some other affection during the course of
which no symptoms suggestive of brain tumour
are observed. In one such case the patient,
himself a distinguished physician, died ten days
after the operation of lateral lithotomy, no com-
plication having occurred. At the post-mortem
an encysted tumour as large as an egg was found
in the right parietal region, containing a blackish
pulpy material and masses of cholesterin (B.M.J.
1875, ii. 453). In other cases one of the
symptoms pointing to cerebral tumour, such as
headache or vertigo, may be present, but a
considerable time, even years, may elapse before
other symptoms occur which warrant a definite
diagnosis of cerebral tumour. In a case which
occurred many years ago, under the care of
Beevor and Horsley, the patient had occasional
N
178 SOME POINTS IN THE SURGERY
fits with unconsciousness, beginning in the
corner of the mouth six years before other
symptoms arose which justified operation, and
then the tumour was found so situated that it
could not be removed without producing aphasia.
A man, aged twenty - three years, died in St.
Thomas's Hospital, under the J ate Dr. Hadden, after
Fig. 78. — A case of tumour of the brain with a long history and with
few symptoms. (Hadden.)
A, B, caudate and lenticular nuclei displaced and flattened out, with the internal
capsule between them.
The tumour had destroyed the whole of the right frontal lobe, and had perforated
the skull by pressure atrophy. The dura was firmly adherent to it for 2^ inches.
The tumour was probably of meningeal origin ; it was composed of spindle cells.
having been comatose for fifteen hours. At the autopsy
a large tumour was found that involved the whole
frontal lobe and part of the brain behind, and had
caused pressure atrophy of the frontal bone in more
than one place. Twelve years previously he had re-
ceived a severe blow over the right eye at football.
OF TUMOUR OF THE BRAIN 179
He had been in the hospital six years before his death,
when he had fits, and again three years before his death
with mental aberration, from which he recovered in ten
days. He was a well-educated man, good at arithmetic
and geometry, and an excellent draughtsman. The
gravity of the case was not suspected till the onset of
the final coma.
In February 1904 I saw, with Dr. Ferrier, a man,
aged fifty-four years, who had complete right hemi-
anopsia, double optic neuritis, occasional incontinence
of urine, slight paresis, both of motion and sensation,
of limbs on left side, and occasional occipital headache.
In spite of his hemianopsia he was a good shot the
previous winter. Both testicles had been removed for
tubercular disease, the right twenty, and the left fifteen
years previously. There was no family history of
tubercle. No history of syphilis. Five years previously
he had " Catherine wheel " visual hallucinations referred
to the left side. He had never had a " fit," nor vertigo,
nor had he vomited. The hemianopsia had been dis-
covered by Dr. Ferrier some months, and the optic
neuritis some six weeks before I saw him. For some
time he had noticed diminution in his power of walking.
On 3rd March 1904 bone was removed over the right
occipital lobe, and a few days later a dural flap thrown
down. A very vascular tumour was found occupying
the cuneus, and the outer aspect of the first and second
occipital convolutions. The tumour, together with a
tail -like prolongation which reached the descending
cornu of the lateral ventricle, was enucleated from the
centrum ovale without serious haemorrhage. A recur-
rence subsequently took place and was removed, but
the patient died two days after the operation.
i8o SOME POINTS IN THE SURGERY
Fig. 79. — Photograph of psammoma (angeiolithic sarcoma) of occipital lobe.
(Dr. Ferrier's case.)
Note the long process, above and to the right, foreshortened in the photograph,
which reached to the middle corner of the lateral ventricle.
\^\
*lf'
<\y
«7i=-"is
t ^^^'^^t^,
r^^
k' ^y^ \^*
'\nni^i<Lj>.
X.500
Fig. 80. — Microscopical section of tumour.
OF TUMOUR OF THE BRAIN i8i
The general symptoms of cerebral tumour,
the syndrome, may be first manifested, localising
symptoms occurring later or not at all, and the
converse may be the case. Localising symptoms
occurring late have less definite localising value
than the same symptoms occurring early.
We have no evidence that a brain tumour
once developed ever spontaneously disappears,
except gumma and perhaps tubercle.
In some instances though the symptoms, so
tar as our present experience goes, seem to indi-
cate pretty clearly the presence of intra-cranial
tumour, the course of events shows that this
diagnosis is in error, and yet a critical review of
the history and symptoms does not show why
the diagnosis went astray. In this category may
be included cases where the symptoms subside,
and the patient remains well for years ; cases
that die and no tumour of brain is found ; cases
that recover after an operation at which no
tumour is found.
No error is fully confuted until we not only
know that it is an error but how it became one,
and until we are in a position fully to explain
such cases, similar errors must continue to occur.
Some may no doubt be explained by the spon-
taneous recovery from localised tubercle, or even
syphilis, but all cannot in this way be accounted
1 82 SOxME POINTS IN THE SURGERY
for. In some of the cases in which operation is
done there is distinct evidence of increased intra-
cranial pressure, but none as to its cause. It
seems that the symptoms we take as indicative
of tumour are the clinical expression of a slowly
increasing morbid process in the brain of which
tumour is not the only possible cause. Nonne
has drawn attention to these cases. Some in-
stances given by him recovered after a course
of anti-syphilitic treatment. It is true their
recovery was delayed, but this does not exclude
syphilis. It is doubtful whether such cases can
fairly be claimed as examples of syndrome
symptoms without tumour.
Sanger has pointed out that in some of these
cases there are microscopic metastases in the
brain from malignant growths elsewhere. Nonne
makes some apt remarks on the difficulty or
indeed impossibility of diagnosing some cases of
chronic hydrocephalus from tumour of the pos-
terior fossa.
I relate several cases with syndrome symptoms
in which no tumour was found, and, by way of
contrast, Dr. Hadden's case of tumour with no
observed symptoms may be referred to (page 178).
The two following cases are taken from
Nonne's paper : —
I. A man, aged twenty -six years, had, without
OF TUMOUR OF THE BRAIN 183
evident cause, particularly without any reason to sus-
pect syphilis, hemiparesis on the left side. This was
accompanied by headache, occasional vomiting, and
abnormal sensations on the left side of the body. A
year and a half later he was admitted to hospital ;
besides the hemiparesis he then had exaggeration of
deep, and diminution of superficial, reflexes, variable
diminution in frequency of pulse, and slight optic
neuritis on both sides. No impairment of sensation.
The skull was not tender on percussion ; the pupil
reactions and speech were normal. Except for a slight
central facial paresis on left side there was no affection
of the cranial nerves. Consciousness and mental con-
dition not altered. No improvement followed mercurial
inunction. He went out after four weeks without
noticeable change in his symptoms. He was re-
admitted six months later ; the hemiparesis had become
more intense, and the abnormal sensations on the left
side had become more troublesome. He also at that
time complained of double vision, and the left external
rectus was paralysed. There were no convulsive move-
ments and no fever. Urine and internal organs normal.
No nose nor ear affection. Anti-syphilitic treatment
renewed. Patient discharged in six weeks ; no im-
provement. Five months later the patient presented
himself well. No treatment had been adopted in the
meantime. The " cerebral " condition of the reflexes
was no longer present, and the fundus oculi was normal.
2. A man, aged thirty years, was taken ill without
evident cause with headache, vomiting, and partial loss
of consciousness ; the symptoms gradually increased in
severity, and there were abnormal sensations in the left
arm and leg. On admission to hospital there was
marked left hemiparesis and hemianaesthesia (for all
1 84 SOME POINTS IN THE SURGERY
kinds of sensation). The hemiparesis was of cerebral
type. Optic papillae normal. Intra-dural pressure some-
what increased (250 mm. water). Torpor and head-
ache at first only got worse under iodide and mercury,
and the left external rectus became paralysed. After
fourteen days improvement began, and in a month
recovery was complete. Patient when last seen had
continued regularly at work for eleven months, the only
abnormality to be detected was that the left knee-jerk
was more marked than the right, though not showing
a pathological degree of increase.
Nonne also refers to a case in which there
were marked symptoms of organic disease of the
left motor cortex. An operation was performed,
but the patient died as a result of injury to the
superior longitudinal sinus. No tumour was
evident to the naked eye, but microscopical
examination demonstrated an infiltrating glioma
unusually poor in cells.
I saw, in 1898, with Dr. Hawkins, Mr. A., aged
thirty-two years. When seen he had paralysis of the
left third, fourth, and sixth nerves, and anaesthesia of
the second division of the fifth nerve, and slight pro-
minence of the eye-ball on the left side. On the right
side there was some weakness of the third nerve.
There was no affection of any limb. Intense papillitis
was present on both sides. Sixteen years previously
he had had a severe fall over the handles of a bicycle.
His illness commenced in 1897 with a fit; this
occurred while he was walking in the street, but
he quickly recovered consciousness and got up and
OF TUMOUR OF THE BRAIN 185
walked home. Two months later he began to suffer
from o-iddiness. Six months after the first " fit " he
had severe pain in the head, vomiting, and the sub-
jective sensation of a disagreeable taste. He felt better
after food. Not long afterwards he began to complain
of diplopia. Optic neuritis was first observed eight
months after the first fit. The anaesthesia of the
second division of the left fifth nerve had been preceded
bv severe neuralgia. He improved considerably under
potassium iodide. Later on his sight steadily deterior-
ated, headache and vomiting were renewed, fits and
neuralgia of second division of fifth recurred and pro-
trusion of the left eyeball was added to the symptoms.
The first stage of operation was carried out on August
28th, 1898, and the dura opened on September 2nd.
The fronto-sphenoidal region on the right side was
examined. The brain bulged under great pressure, but
no tumour was found. A few days after the operation
the patient died. No tumour was found at the autopsy.
Microscopical preparations were made by Dr. Purves
Stewart from various portions of the brain, but no
histological changes were detected.
Dr. James Taylor recently published a remarkable
case : — The patient was in the hospital fifteen years ago ;
the history of the case is extremely interesting, as is
also the sequel. He came first of all on account of
severe headache and vomiting. He also had intense
optic neuritis and right-sided weakness, affecting both
the arm and the leg. In addition there was very great
difficulty with speech. He became rapidly worse, the
impairment of power in the limbs became much greater,
and the weakness spread so as to affect the opposite
side. In course of time he became completely para-
i86 SOME POINTS IN THE SURGERY
lysed in all four limbs. At this time he was also
unconscious, taking no notice of anything which was
said to him, and only swallowing, and that automatically,
when anything was put on the back of his tongue. The
surgeon's opinion was that it was not the kind of case
in which operation could be reasonably expected to do
good. The patient remained unconscious for about
two months, completely blind and deaf. Then he
began gradually to recover, and in some months he
attained his present condition. The only disability with
which he is left — a most unfortunate one — is a very
grave defect in vision on account of the intensity of the
optic neuritis, which had proceeded to atrophy. During
fifteen years he has remained quite well except for that one
defect. He is a man of considerable intellectual ability.
The case illustrates the fact that, however hopeless
the condition of a patient may appear to be, it is pos-
sible for him to recover from a very severe degree of
paralysis without impairment of mental functions. And
it also illustrates that the great danger of these cases
which recover is that permanent and grave impairment
of vision is apt to remain. The question of the nature
of such a tumour is one of very great interest, and in
this case I think there was some reason for supposing
that the tumour was probably tuberculous in character.
The following three cases are examples from
my own experience of recovery after operation
at which no tumour was found : —
I. A man, aged forty-three, under the care of Sir
W. Gowers in the National Hospital. (Notes by Dr.
Singer.) Father and two brothers died of phthisis.
No previous illness except influenza in 1894 or 1895.
No venereal disease. Began in May 1900 with head-
OF TUMOUR OF THE BRAIN 187
ache, which recurred daily, mostly in the evening, and
was associated with nausea and on one occasion vomit-
ing. Headache rather more severe on right side of
forehead and vertex. Sight began to fail one month
later, and he had diplopia. Soon after began to be
deaf in right ear, and in August 1 900 also in left. At
that time he had lost 16 lbs. in weight in less than one
year. On admission^ August 24th, 1900, he was very
slow and heavy, paused for some time before answer-
ing even a simple question, and spoke slowly, though
without definite abnormality. No bulging or localised
tenderness in the skull. Smell and taste normal.
Vision, right, -^ ; left, -^'^. No contraction of visual
fields to rough test. Well - marked optic neuritis,
swelling on both sides, 2 D. Watch heard on right side
at 4 feet, on left at i foot. Diplopia in all directions,
but no obvious strabismus or weakness of ocular muscles.
Right pupil larger than left, but both act well. No
affection of motion or sensation. September ^th. —
More drowsy, pain in head constant. O.D.'s much
more swollen, being 6 D. on both sides. The left
K.J. is now greater than the right, and the left plantar
reflex is now of extensor type. No ankle clonus.
September 12th. — A. tender spot was found on the skull
about the middle of the right half of the coronal suture.
Operation, September 1 2th.- — Bone removed over right
frontal region ; bone very dense and thick and bled
freely. Dura very dense and bulging. Second Stage^
September 10th. — Dura opened and about i ounce of fluid
escaped. Bulging of brain. No tumour seen or felt.
October %th. — Free from pain since last operation.
Note. — The following abbreviations are sometimes used : —
O.D. = optic disc. K.J. = knee jerk.
A.J. = Achilles ierk. S.|. = supinator jerk.
1 88 SOME POINTS IN THE SURGERY
Swelling of O.D.'s, right, 6 D. ; left, 6.^ D. ; one or
two haemorrhages in left disc. November ()th. — Leaving
hospital to-day. Mental condition improved, but still
dull. No pain, but is giddy when walking. Optic
neuritis as before. Still has well - marked plantar
extensor response on the left side.
After discharge was away in the country and steadily
improved, lost his giddiness and could walk ten miles
easily. No headache. December list. — Vision, right,
j^ ; left, -^^. Right disc, no swelling; left, 1.5 D.
Visual fields normal.
Patient remained quite well, getting gradually on to
full work until Easter 1903, when he had some return
of headache and giddiness, with mental obscuration and
loss of appetite, lasting several weeks but finally passing
off quite suddenly. A second similar attack came on
about two weeks later, and he was admitted to St.
Thomas's. He then presented a good deal of mental
slowness, and had some frontal headache, not nearly as
severe as before his operation. There was no fresh
optic neuritis, and his vision was practically perfect.
He still had an increased knee-jerk on the left side,
with an extensor plantar reflex on that side, but no
fresh signs. He left the hospital practically well, and
when last heard of was quite well.
2. Mrs. B., aged thirty-two (patient of Drs. Ferrier
and Purves Stewart). — Never robust ; subject to anaemia.
Married eleven years, three children, aged 10, 6, and
I year. No injury or accident. No ear trouble. No
scarlet fever. In September 1904, six or seven weeks
after the birth of last child, began to have attacks of
diffuse headache and violent nausea. Was lactating at
the time, and continued to nurse child until it was
OF TUMOUR OF THE BRAIN 189
three months old. After, for two or three weeks, she
had acute attacks every few days. The pain then
subsided to an ordinary (retro-ocular) headache, such as
she had been subject to since the age of sixteen. Head-
aches gradually became more frequent and more acute.
At the end of April 1905 headache became associated
with retching and with mistiness of vision, and with
numbness in legs and inability to walk with comfort.
Also felt faint when standing up suddenly or when
walking up or down stairs.
July I'ith, 1905. — Complains of headache, chiefly
occipital and pain down back of neck, worse in the early
morning. Headache reaches its maximum in about
ten minutes, and is associated with intense nausea (no
vomiting) and with mistiness of vision coming on in
" waves." Occasional slight diplopia, no giddiness.
Legs feel clumsy and wooden, especially the left.
Intelligence, speech, and articulation normal. Patient
left-handed. Intense double optic neuritis. Visual
fields normal. Vision, right, -^^^ ; left, j-^. Pupils,
2.5 mm. Left not quite circular externally. Ocular
movements normal. Smell and taste acute on both
sides. Hears watch at 6 inches in right ear, at 9 inches
in left. Tuning-fork on vertex heard equally in both
ears. Face pallid. Tongue normal. Sensory func-
tions normal. No motor paralysis of limbs. Rapid
rotatory movements of pronation and supination per-
formed somewhat faster on left side. Movements of
lower limbs not energetic, but none impossible. No
ataxy of lower limbs. Gait feeble and uncertain. No
spasticity. Can stand on either leg alone, but slightly
more steadily on the left leg. Reflexes normal. Difiaise
tenderness all over back of head. Lumbar puncture
withdrew fluid under excessive pressure, in which a
190 SOME POINTS IN THE SURGERY
moderate number of lymphocytes were found. Heart,
lungs, and abdomen normal. Urine loio, no albumen.
Mr, Gunn reported i D hypermetropia in both eyes, 2
dioptres swelling in right disc, 3 dioptres swelling in left.
July list — First Stage of Operation. — Flap turned
down in left occipital region. Large area of bone
3" X 2" removed. Dura tense and with little pulsation.
July i\t}i — Second Stage of Operation. — Dura opened
and left occipital fossa thoroughly explored. No tumour
found. Scalp wound closed. Dura not stitched.
August I St. — For the first two or three days after
operation patient felt as if she were sinking downwards
through the bed. This passed off. Pupils equal and
normal. Visual fields normal. No squinting. No
diplopia. No nystagmus. Cranial nerves normal. No
anassthesia of face, trunk, or limbs. No motor weak-
ness, or inco-ordination of upper or lower limbs as
patient lies in bed. Reflexes normal and equal.
Cerebro-spinal fluid still escaping from outer angle of
wound. Wound otherwise healed. No headache.
August \oth. — All stitches removed several days ago.
Temperature normal. No headache or vomiting. Discs
examined to-day. Swellings rather less : about 1.5 D.
in right eye, a little more in left. August 30//;. —
Leaking of cerebro-spinal fluid continued until yester-
day, when it ceased. Discs seen to-day by Mr. Gunn.
Edge of right disc now clear except on inner side.
Edge of left disc still blurred. Swelling less than i D.
in each eye. No pallor. No contraction of fields.
September 1 3//?. — Discs pink, but no measurable
swelling. Rapid rotatory movements of forearms are
less quickly performed on left side than on right, also
slight unsteadiness in pointing to small objects with left
foot. K.J.'s brisk and equal. Plantars flexor.
OF TUMOUR OF THE BRAIN 191
April ind, 1906. — Has been at Littlehampton for
six months. Still feels unsteady in going up or down
stairs. Likes to be near surrounding objects, but does
not reel. Some giddiness on stooping. No spontaneous
Fig. Si. — Mrs. B., patient of Dr. Ferrier, fourteen months after operation.
The flap still bulges considerably.
giddiness. Goes downstairs always right foot first,
comes up left foot first. Occasional neuralgic pain
behind eyes if tired. Once or twice had nausea, but no
vomiting. No diplopia. No unsteadiness in hands on
sewing or crocheting. Marked bulge in left suboccipital
region. Pupils and external ocular movements normal.
192 SOME POINTS IN THE SURGERY
No diplopia, no nystagmus. Face, palate, tongue
normal. Hearing acute both sides. No anaesthesia.
Discs good colour, no swelling. K.J.'s and AJ.'s brisk
and equal. Plantars flexor. No diadocokinesis. Slight
tremor of left lower limb on pointing to objects.
Stands alone on one leg, better on right leg than on
left. Gait still slightly unsteady.
July ^rd, 1906. — No giddiness now, but still likes to
be near surrounding objects. Still same method of
going up and down stairs as before. No headache or
vomiting. Left disc a little less clearly defined than
right. Pupils and cranial nerves normal. No un-
steadiness in pointing to nose with either hand. S.J.'s,
K.J.'s, A.J.'s normal and equal.
Remarks. — In this case the symptoms seemed to
point conclusively to the existence of gross disease in
the occipital fossa, but were inconclusive as to the site
of the disease. The greater relative prominence,
tenderness, and dulness of the left cerebellar region,
and the greater intensity of the optic neuritis in the
left eye, led me to operate on that side.
3. F. T., male, aged twenty. — Sent to me by Dr.
Bernard of Londonderry in September 1903. Paternal
grandfather died of malignant disease in abdomen.
Paternal aunt died of phthisis. No nervous or mental
disease in any relation. Patient complains of recurrent
attacks of vomiting. The first attack fifteen months
ago, in June 1902. He had headaches for a couple of
weeks at that time and had sudden vomiting lasting two
days. At that time he used to knock his right shoulder
against the wall of a white-washed corridor at home.
During the next two months he had three or four more
attacks of vomiting. He then remained perfectly well
d
OF TUMOUR OF THE BRAIN 193
for three or four months, able to hunt, etc. Last
Xmas went to BerUn and thinks he caught cold on his
way back to Ireland. Gradually occipital headaches
recurred and almost daily vomiting. In March was
so ill with vomiting that he was fed for a week by
enemata. Another relapse in May and again in June
lasting a week. Since then has had two days' sickness,
one in Julv and the last a week ago. Attacks consist
of sudden vomiting, usually bilious. No known ex-
citing cause, dietetic or otherwise. Never lost con-
sciousness during attacks. No ear trouble. Has
astigmatism, for which he wears glasses. Bowels tend
to be confined. In July last had diplopia for a couple
of days, the images appeared not on the same level,
also a certain amount of photophobia. Reading tires
him. Occasional giddiness when stepping off a tram-
car. No weakness of arms or legs.
Condition^ September 26ih, 1903. — Intelligent, well
developed, speech and articulation normal. Discs
show deep physiological pits. No neuritis or atrophy.
Visual fields normal. Pupils, face, palate, and tongue
normal. No squint or diplopia. Marked coarse
nystagmus on looking to the right, slighter on looking
to the left. No anaesthesia of face, trunk, or limbs.
No weakness or ataxia of arms or legs. Gait normal.
S.J.'s left greater than right. K.J.'s left greater than
right. A.J.'s left present, right absent. Plantars flexor.
No cranial tenderness. Heart, lungs, abdomen, normal.
Urine, no albumen, no sugar. October 1st. — Sir
Anderson Critchett agrees as to the nystagmus, and
says it was not present when he saw the patient eight
months ago. The nasal sides of both discs are
suspicious ; not quite clearly defined, but with a
little swelling not amounting to actual papillitis..
o
194 SOME POINTS IN THE SURGERY
October iGth. — Well-marked diplopia to the right.
The false image seen by left eye is displaced down-
wards below the true, but is practically parallel with it.
The nystagmus as before. No weakness of face or
limbs. Hearing acute on both sides, S.J.'s and K.J.'s
left greater than right. A.J.'s left present, right absent.
Reels slightly when walking, but keeps in a straight line.
October 1,0th. — A small haemorrhage is now present
in the left disc at its inner margin. Two days ago had
sudden flushing of the face for a couple of minutes
with slight headache ; no giddiness. Only one slight
attack of vomiting since last night. Diplopia less
troublesome. Reeling as before. Diplopia occurs on
looking to extreme right, the false image with the left
eye being below the true, and with its upper end lean-
ing away from the true, i.e. to the right. K.J.'s left
greater than right. A.J.'s left present, right absent.
November ^th. — Patient's mother writes that he is
more unsteady in picking up small objects, and when
cutting his food misplaces his knife. November list. —
Haemorrhage in left disc is as before. Swelling of left
disc greater than right. Diplopia to extreme right as
before. Nystagmus almost gone, still present on looking
to the right. Reflexes as before. Difficulty in cutting
food with right hand some four or five days ago. No
headache. December lyz/z. — Has had three bad attacks
of headache, and vomiting at intervals of seven days.
Seems to feel particularly well before each attack. One of
these attacks lasted three days. Headache commences
as steady aching pain in right eye, gradually diff^using
all over the head, and with paroxysms of agonising pain
in the back of the neck mesially, especially when bowels
move. Has noticed aggravation of diplopia after each
attack. Haemorrhage of left disc almost gone. The
OF TUMOUR OF THE BRAIN 195
inner edge of the disc is swollen much more than
before. The right disc is now moderately swollen as
well, especially on its inner edge. The diplopia to the
right less marked. Images not definitely separated as
before. Coarse horizontal nystagmus to the right.
Pupils equal, moderately dilated, reactions normal. Face,
hearing, tongue, palate, normal. Reflexes as before.
Very slight reeling on turning rapidly. No difference
in rapidity of alternate pronation-supination movements
on two sides. No abnormal static rigidity of either
lower limb. No cranial irregularity or tenderness.
December i8//z, — Lumbar puncture. Four drachms
of clear fluid under abnormal pressure, containing a
few mononuclear cells, December 31 J/. — No nystagmus,
no diplopia, headache less. No unsteadiness in walking,
but knocks right foot against curb on regaining the
path. Reflexes as before. Discs in statu quo.
January 14/^, 1904. — Felt particularly well until the
9th, when he had a recurrence of severe headache and
vomiting. Diplopia and nystagmus reappeared with
greater intensity, I saw him during the attack and
noted distinct local tenderness in right occipital region.
Optic neuritis has increased and now measures up to
2^ dioptres in both eyes, the right more than the left
(measured by Mr. W, T. Lister yesterday). Slight
reeling when turning. Reflexes as before. Dr.
Ferrier, Dr. Pye-Smith, Dr, Purves Stewart, and Sir
Victor Horsley all concurred in advising operation in
right cerebellar region.
January i6th. — Operation. Bone over right cere-
bellar region was removed. Dura was dense and
bulging. Lumbar puncture was then performed, and
about half an ounce of clear fluid was withdrawn under
considerable pressure. Removal of this fluid reduced
196 SOME POINTS IN THE SURGERY
the cerebellar dura to a flaccid, non-bulging condi-
tion. January 2'^rd. — Dura opened ; lumbar puncture
having previously been done, and about i:^ ounces of
cerebro-spinal fluid withdrawn under excessive pressure.
No tumour was detected by the finger in the right
cerebellar fossa external to the cerebellum, and none
was found after horizontal section of the cerebellar
hemisphere.
January iZth. — Patient languid and restless. No
actual paralysis of cranial nerves or of limbs, but he seems
to have difficulty in moving himself in bed. Intelli-
gence perfect. Copious escape of cerebro-spinal fluid
from angle of wound. February ^th. — No headache,
no vertigo, no vomiting. Articulation much better but
not normal. Fluid still leaking. Still marked diplopia
to the right. Coarse nystagmus to the right, fine to
the left. Marked unsteadiness of right upper limb.
Cannot feed himself with the right hand. No difference
between lower limbs in pointing to small objects. S.J.'s
and K.J.'s left greater than right ; A.J.'s left present,
right absent. February i^th. — Mr. Lister examined
discs again to-day. Swelling reduced to half a dioptre
in both discs. Marked unsteadiness of gait, and right
hand in reaching very unsteady. Fluid escaping
copiously.
March 14^/2. —Wound hardly leaking at all. No
unsteadiness on walking. Slight diplopia to the right.
Coarse nystagmus to the right. Some bulging of flap.
Discs, left practically normal ; right, a little indistinct
at edges but no measurable swelling. March 22nd. —
In the right disc veins are a little tortuous. No
measurable swelling, moderate nystagmus on extreme
lateral division, right greater than left ; none on vertical
rotation. Face, tongue, palate, normal. Occasional
OF TUMOUR OF THE BRAIN 197
diplopia to the right, not constant. Sensory functions
normal. No unsteadiness of upper or lower extremities
on pointing to small objects. Gait normal. S.J.'s,
K.J.'s, A.J.'s, left greater than right. Plantars flexor.
May 1st. — Patient remained well until two days
ago, when he vomited all day long and had pain in the
right eye. Ten days ago had similar pain without
vomiting. Now feels well. Moderate bulging of
flap ; discs practically normal (Lister). Very slight
weakness of right face. No deafness. Articulation
normal. Slight nystagmus to the right and slight
diplopia to the right. No anaesthesia, no weakness or
unsteadiness of arm or leg. S.J.'s and K.J.'s, left greater
than right. A.J.'s, left present, right not elicited.
September 26th, 1904.— Feels well except for occa-
sional giddiness at the moment of waking in the morn-
ing. Still diplopia to the right. Hearing acute on
both sides. Cranial nerves normal. No unsteadiness
of limbs. S.J.'s, K.J.'s, A.J.'s, normal and equal. Gait
normal. Scar in right occipital region bulges moder-
ately. Gentle pulsation.
December 14//2. — Since last note has been to various
places in England and feels very well. Has occasional
sudden feelings of giddiness the first thing in the morn-
ing. Still diplopia to the right. Coarse nystagmus
as before to both sides, especially to right. Right
palpebral fissure slightly wider than left. Cranial
nerves otherwise normal. Gait normal. Reflexes
normal and equal on two sides. Discs practically
normal.
January 2^rd^ 1906. — Patient is quite well. Can
play two rounds of golf without fatigue. Occipital
operation flap now concave.
Remarks. — All who saw the patient agreed that the
198 SOME POINTS IN THE SURGERY
symptoms pointed to tumour occupying the right
cerebellar fossa. The symptoms suggesting a right-
sided lesion were the slight inco-ordination of the right
Fig. 8z. See Fk. 8
hand, the greater swelling of the right optic disc, the
absent right A J., the diminished right KJ,, and S.J.,
the coarse nystagmus on looking to the right, and the
history that in walking down a passage he tended to
deviate to the right, and in crossing the road he knocked
the right foot against the curb.
OF TUMOUR OF THE BRAIN 199
As a practical operation detail I wish to draw atten-
tion to the value of lumbar puncture before opening
Fig. 83.
Figs. 82, 83. — Back and side views of head of Mr. T. (Sept. 1906), two years and
nine months after operation.
The bulge is considerable, and is now more marked than it was a year ago. For
the last six months his golf has been poor owing to double vision, and six weeks
ago he had a severe attack of pain in right eye and vomiting.
the dura when there is much intra-cranial pressure.
This procedure facilitates exploration and saves the
brain tissue from damage.
200 SOME POINTS IN THE SURGERY
Relation of Injury to Tumour Growth.
Malignant growths have in some instances
a purely local origin, in the same way that
tubercular infection may arise from direct in-
oculation and remain a local though a spreading
disease. Local irritation or injury often precedes
the actual presence of tubercular or malignant
disease. Against the view that local irritation
or injury is associated with the outbreak of
these diseases, the main argument adduced is
that a large proportion of those exposed to local
irritation or injury should become the subjects
of these diseases. But the efficient cause lies
beyond the mechanical irritation, which is but
the partial cause of the disease, and the question
resolves itself into this : Why are some persons
infected in such circumstances whilst others
escape ? It is beyond the scope of my present
purpose to attempt an answer to this question, but
as in other parts of the body so in the head, injury
is sometimes followed by malignant disease.
Many such cases might be cited of which
the following are good examples : —
I. A boy, ten years old, had a blow on the head
and afterwards suffered continuously from headache
and vertigo ; nine years later he began to suffer from
cerebellar ataxy, the general symptoms of brain tumour
gradually showed themselves, and death took place
OF TUMOUR OF THE BRAIN 201
f^H^
Fig. 84.
Fig. 85.
Fig. 86.
Figs. 84 and 85. — Healed fracture, outer and inner surfaces of skull, over
gliomatous tumour in occipital lobe.
Fig. 86. — Cystic glioma of occipital lobe under healed fracture of skull. The
cavity in the tumour appears black ; the extent of tumour is shaded a grey tint.
202 SOME POINTS IN THE SURGERY
suddenly. A sarcoma was found in the middle lobe of
the cerebellum. (Duret, p. 40.)
2. In 1895 I operated for brain tumour on a coach-
man, aged thirty-one years, whom I saw in consultation
with Mr. Lunn and Dr. Beevor. He had suffered
from headache for a year, and his sight had been failing
for nine months. A history was obtained of hemi-
anopsia having been observed in another hospital. On
admission he had severe headache and vomiting. He
was almost totally blind, and hearing was much im-
paired on both sides. Both discs atrophic from optic
neuritis. Mental state tending to torpor. No paralysis
of motion or sensation, but tendency to fall towards
the left side. He denied having met with any injury
to the head. At the operation a healed fracture was
found in the right occipital region, and it was afterwards
ascertained that twenty years previously he had been
kicked by a horse, and had remained unconscious for
some hours afterwards. Beneath the healed fracture
was a cystic glioma of the occipital lobe.
3. Case by Dr. Dudley. — A male adult was struck
on the right side of the head with a stick, he was un-
conscious for twelve hours after the injury, on recovery
he had slight headache. Three days later he had a fit.
The wound healed in two months. The fits continued
for eleven months. He was trephined six months after
the accident on the right side, and for a time was much
improved. A year after the injury he was admitted to
hospital with weakness of the right leg. There was a
cicatrix on the right side of the head and tenderness
over the opposite parietal region. The fits recurred
and tactile sensibility on right side was gradually lost.
He died three months later. A soft glioma was
found in the posterior part of the left frontal lobe
OF TUMOUR OF THE BRAIN 203
as large as a Tangerine orange. The tumour was
apparently the direct result of the injury.
4. F. C, female, aged twenty -one years, was
admitted to St. Thomas's Hospital under my care on
March 27th. In the previous August she fell, striking
the left frontal region against an iron spike. There
was a wound which bled freely, and the patient was un-
conscious for twenty-four hours. She was admitted into
Grantham Hospital under Dr. Shipman. From the time
she recovered consciousness until her admission to St.
Thomas's seven months later the only symptoms observed
were occasional attacks of headache and repeated bleeding
from the wound, which did not heal. It was for this
repeated haemorrhage that the patient was sent to me.
On admission to St. Thomas's there was a wound in
the upper left frontal region about the size of a shilling,
surrounded by scar tissue, which led into a cavity within
the skull. There was no optic neuritis, and careful
examination failed to detect any focal symptoms.
Operation. — An oval scalp flap wa's thrown down
including the wound ; this exposed a hole in the bone
as large as a shilling, many bleeding points were seen
in the bone surrounding this opening, a condition which
I have previously met with during removal of angio-
sarcoma of brain. A considerable area of bone was
removed. This revealed an opening in the dura corre-
sponding to that previously found in the bone ; through
this opening the finger passed for two inches into a
cavity with thick walls. A dural flap was then made, the
supposed meningo-cortical abscess was enucleated entire,
and the operation completed in the usual way with drain-
age. At the bottom of the abscess cavity was a particle of
hard material which gave the chemical reactions for iron.
The patient did fairly well for some days, except that
204 SOME POINTS IN THE SURGERY
there were repeated small haemorrhages from the wound,
on which the local application of adrenalin and turpen-
tine, and the internal administration of calcium chloride,
had no effect. On the twenty-second day a severe
haemorrhage suddenly occurred and the patient became
comatose, with subnormal temperature, slow pulse, and
slow respiration. The unconsciousness was due to a mass
of clot which had collected in the cavity left at the first
operation, and torn up the surrounding brain substance.
When the clot was removed there was immediate
improvement. Several vessels in the brain were ligated.
Some days later, as slight haemorrhages repeatedly
recurred, the left carotid was ligated. A week later
the patient died ; the temperature rose to 107° im-
mediately before death.
Repeated microscopical examinations during the life
of the patient failed to reveal the presence of malignant
disease, but when the brain was examined after death
many discrete nodules of new growth could be seen
with the unaided eye in the neighbourhood of the
injury, some of which involved the pia. Some had
haemorrhages around them, others were distinguished
only by their whiter colour. On microscopical ex-
amination these masses proved to be angeio-sarcoma,
containing numerous vessels with thin and undeveloped
walls from which blood had obviously escaped in many
places. Clotting had taken place in the internal carotid
and its middle cerebral branch. A ligature was found
on one of larger branches of the middle cerebral.
Remarks. — This patient's brain must have been
inoculated in many places with the virus of malignant
disease as surely as a tube of culture medium is in-
oculated by plunging into it a platinum point deliberately
charged with infective material.
0
OF TUMOUR OF THE BRAIN 205
Fig. 87. — Photograph of supposed meningo-cortical abscess removed at the first
operation on Dr. Shipman's case.
Note. — The external opening is seen, and the thickness of the wall of the abscess.
Fig. 88. — Tumour of frontal lobe following punctured fracture of skull.
(Dr. Shipman's case.)
Coronal section (partly diagrammatic) just behind the chiasma. A portion of
the cavity in the brain at the time of death is represented. The dark parts are
haemorrhages ; G, G, G, discrete nodules of growth, grey in colour, without
haemorrhages'; a, internal carotid artery and its middle cerebral branch, the latter
with its striate branches.
2o6 SOME POINTS IN THE SURGERY
Figs. 89. /o 95 illustrating the Histology of the Tumour —
Dr. Shipmans Case.
The obviously diseased area was made up of growth and degenerated and inflamed
brain substance with much extravasation of blood. Sections taken from just beyond
this area showed discrete nodules of sarcoma in the pia, many visible to the naked
eye in the stained sections. The pia, where affected, was thickened, highly
vascular, and infiltrated with round cells ; the walls of many of the vessels were
infiltrated with sarcoma. The processes of pia extending into the smaller sulci
were in many cases clearly infiltrated with growth, and the vessels entering the
brain substance carried sarcoma cells with them. The brain cortex was edematous,
and its perivascular spaces were dilated. Some of what appeared to be outlying
nodules of new growth surrounded by a zone of haemorrhage were really islets of
more or less degenerated brain substance completely enclosed by processes from the
pia infiltrated with growth. Others were definite nodules of sarcoma. The spread
of the growth along blood-vessels could be clearly demonstrated, and in sections
stained by the orcein and thionin method, introduced to my notice by Professor
Goldmann of Freiburg, examples of vessels destroyed by the growth were well
shown. In sections taken from the deeper part considerable areae of sarcoma could
be seen, in which were many vessels of new formation with thin and undeveloped
walls. Haemorrhages had occurred both from old and new vessels. Streaks of
comparatively unaltered brain tissue were in places to be seen between masses of
extravasated blood. I am indebted to Dr. Charles Green for the preparation of the
microscopical specimens.
^
Fig.
-A drawing made of section from the brain cortex just beyond the
obviously diseased area.
Several darkly-stained areae, which are nodules of sarcoma, are seen in the pia.
Two processes of pia are seen, one fairly normal, the other much thickened and
OF TUMOUR OF THE BRAIN 207
infiltrated with sarcoma cells. In the brain substance a large nodule of sarcoma
without definite limits is seen. The specimen was stained with logwood.
The appearances in this section seem to resemble the microscopical appearances
found in the case reported bv Sanger, in which the pia only was affected (referred
to on page 182), which, in the brief account to which I had access, are thus
described : — "The pia over the convexity was much infiltrated by fairly large cells
with large nuclei 5 some of the cells were round, some oblong, and some caudate ; in
many places the cells formed close agglomerations, in others small areas of pia were
free, except for small groups of carcinoma cells."
^it^ri■^\^■^<^^f^.'y^.r^.ti^|^iff:i^i■'fiV•^^'Sif^^■^iJ?^z^:'i^
* . - ^li^'^'^iy^'
;;-;^-^'\s
Fig. 90. — Reproduction of a drawing made from a section through what appeared
to the naked eye as a nodule of new growth surrounded by a ring of haemorrhage.
It is an islet of brain substance enclosed in a ring of pia infiltrated with new
growth. In the enclosed portion of brain tissue the noble elements have to some
extent perished, and immediately without the ring of pia is a zone of degenerated
brain substance.
The specimen was stained with orcein and thionin blue, and the drawing made
under a one-inch objective.
2o8 SOME POINTS IN THE SURGERY
Fig. 91. — Reproduction of a drawing made of a portion of a vessel in the pia
as seen under a high power.
The vessel happens to be cut at a point where a tiny branch is given off. A
group of rather large sarcoma cells can be seen almost at the angle of junction of the
branch with the main vessel. The elastic tissue of the main vessel is well shown.
In other sections the walls of the branch were seen to be infected with sarcoma
for a considerable distance.
OF TUMOUR OF THE BRAIN 209
■'^i i
■'*.'"
■v{;'
,■■-■-, '.., '■>
* ' » >■,
^ I'."!" '
'•" ^"1
• •;•
♦* i-i ■■
.', \-
•*5
► ' «.*■ ** ' -
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5^
; - i ■-
*'■■ ■** ■ ,l'
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t ,
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Fig. 9:
Fig. 93.
^V>;-^
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Fig.
94.
Figs. 92, 93. 94. — Reproduction of drawings of degenerated vessels as seen
under a high power.
Fig. 92. — The general outline of the vessel is clearly shown by its elastic lamina,
which has taken the characteristic stain, but at one point it is almost completely
destroyed. The other tissues of the vessel wall are almost completely degenerated.
Fig. 93. — Two small vessels in which the degeneration is more advanced. Only
fragments of the elastic laminae are recognisable.
Fig. 94. — A small vessel cut obliquely. Remnants of the elastic laminae are
clearly seen, but the wall of the vessel is almost entirely replaced by sarcoma tissue.
The vessels represented in these three figures were all in the same section taken
from the obviously diseased area, and quite close to the operation cavity.
The section was stained with orcein and thionin blue.
2IO SOME POINTS IN THE SURGERY
Fig. 95. — Reproduction of a drawing of part of the wall of an artery.
The adventitia is infected with sarcoma cells, the tunica media has degenerated,
and the elastic membrane is bulged at one point where the vessel seems about to give
way.
The section was taken from the obviously diseased area, and quite close to the
operation cavity. The particular vessel was easily visible to the naked eye. The
specimen was stained with picro-indigo-carmine.
OF TUMOUR OF THE BRAIN 211
Tumours of the Cranium a?2d Meninges
Brain symptoms may arise from tumour of the
cranial bones or of the meninges as well as from
tumours of the brain itself. The tumours of the
cranial bones which are of chief importance
in this relation are sarcoma and carcinoma,
though other varieties of tumour, such as
angeioma, enchondroma, or osteoma may also
cause brain symptoms. Sarcoma of a cranial
bone may grow outwards and not involve the
brain. The destruction of the cranium is in
some cases wide-spread and terrible.
Carcinoma of the skull or its contents is rare,
and when it occurs it is generally secondary to
carcinoma of the breast. It may develop
secondarily in the skull, as it often does in other
bones, or it may infect the meninges, causing a
tumour which may irritate or compress the
surface of the brain. Carcinoma has also been
known to occur in the scalp, and to perforate
the skull and meninges, as in the cases cited from
Mikulicz and Braun.
Sarcoma of the dura mater may grow from
its outer aspect, destroying the bone, but not
perforating the dura, as in Auvert's case. Indeed
the dura seems to offer considerable resistance to
212 SOME POINTS IN THE SURGERY
perforation by sarcoma, whether from within
or from without.
Tumours of the meninges of common
occurrence within the dura are fibroma, fibro-
sarcoma, endothelioma, and soHtary tubercle.
These tumours either compress the brain, making
a depression in which they are found, or seem
at first sight to occupy the substance of the
brain, but then on careful examination an
attachment to the meninges is found showing
their real origin.
The following cases illustrate some of these
remarks : —
1. Parosteal Sarcoma. — A female child, eighteen
months old, was under my care in the Great Ormond
Street Hospital. A tumour had been noticed on the
left side of the head some three months. The growth
was removed ; it was limited externally by a delicate
'Capsule, and grew from the outer layer of the periosteum
over the squama. The bone was not involved. Three
months later the growth recurred, but no further
operation was attempted. The growth ulcerated and
the child died in about two months from cachexia
induced by the discharge and haemorrhage. (Figs. 96
and 97.)
2. Periosteal Sarcoma of the Squama. — Male, aged
ten years, was admitted to St. Thomas's Hospital in
1898. One year before admission a tumour, the size
of a small nut, was noticed above the right ear. Nine
months later it was excised at the Staines Cottage
Hospital. Rapid recurrence took place, and on
OF TUMOUR OF THE BRAIN 213
admission to St. Thomas's Hospital the photograph
reproduced was taken. The direction of the eyes is a
photographic effect, and not due to any intra-cranial
complication, (Fig. 98.)
Operation. — A skin flap of the whole temporal
region, including the pinna, was turned downwards, the
cartilaginous meatus being divided. The bone was
exposed above, behind, and in front of the limits of the
tumour. The skull was divided in the same direction,
the incision in the bone being horse-shoe in shape,
with the convexity upwards. Patient then became very
faint, was infused, and put back to bed. Two days
later the boy was again an^sthetised. The wire of a
Gigli's saw was passed between the extremities of the
horse-shoe cut in the skull, coming out in front near
the anterior part of the zygoma and behind near the
mastoid process. The saw was then worked vertically
downwards, so dividing the squama and most of the
mastoid from the petrous. Though the tumour
occupied the whole of the temporal fossa it was
attached only to the squama, and was subperiosteal in
origin. It was white on section, and microscopically
was a small, round-celled sarcoma.
Patient left the theatre in fair condition, but shock
was considerable, and though twice infused, death
occurred thirty hours later.
3. Cavernous Angeioma {without Sarcoma Cells) of
Os Frontis projecting backwards into the Skull Cavity
and compressing the Frontal Lobe. (Zajaczkowski of
Poland. From Sawicki's article in Chipault, vol. ii.) —
The patient was a woman aged thirty-eight years.
When seen there was a tumour as large as a hen's egg
above the right orbit. Twelve years previously a hard,
fixed swelling had appeared above the orbit, which in
214 SOME POINTS IN THE SURGERY
six years grew to the size of a hen's Qgg, and was then
removed with the gouge. The bone wound bled very
freely. Recurrence began a year after this operation,
and in five years the growth was as big as ever. The
edges were indurated, the centre soft and pulsatile, and
the overlying skin thin and cyanosed. No effect was
produced by compression of the tumour or of the
vessels. The patient complained of headache and
vertigo, and had mental depression alternating with
periods of excitement. Zajaczkowski removed the
growth, together with a portion of the dura to which
it was adherent. There was a considerable depression
in the frontal lobe. The wound in the dura was
sutured, part of the anterior wall of the frontal sinus
which was involved was removed, and the gap then
covered with a skin flap. The patient recovered, the
headache and vertigo disappeared, but some mental
dulness persisted. (Fig. 99.)
4. Sarcoma of Orbital part of Os Frontis displacing
Dura and Brain. (Preindlsberger, of Serajevo, in Bosnia.
Chipauit^ vol. ii.) — The patient, a man aged twenty-
four years, was admitted to hospital with a tumour as
large as the egg of a goose, presenting at the supero-
external angle of the right orbit. He could give no
account of the tumour, and only applied for treatment
because it was rapidly increasing in size. The growth
was enucleated together with the eyeball. A con-
siderable part of the orbital wall had been destroyed,
but the dura mater appeared unaltered. The day
following the operation there was slowness of pulse
lasting twenty-four hours. The wound united by first
intention. The growth was sarcoma. (Fig. 100.)
5. Recurrent Sarcoma of Outer Aspect of Dura Mater
compressing left Frontal Lobe. (Durante. Roncali in
OF TUMOUR OF THE BRAIN 215
Chipault ^Yo\. iii.) — The patient was a woman, aged thirty-
five years. For about a year before the first operation
she had had loss of smell and impairment of memory, and
had become melancholic and taciturn. The left eye
was displaced outwards and downwards. The skull
was opened by Durante's tangential osteo-plastic flap,
made by incising soft parts down to the bone, and
then, instead of elevating periosteum, chiselling off" the
external table of the bone so as to raise the periosteum
with the external table attached to it in fragments of
about one square centimetre. A tumour was found
which had perforated the dura mater at the level of the
anterior part of the left frontal lobe. The growth was
removed with some difficulty and the wound closed.
The patient recovered and remained perfectly well
for six months ; at the end of that time she had an
epileptic fit with unconsciousness lasting forty- eight
hours. A year later a second attack occurred, and
subsequently attacks were repeated with increasing
frequency. Sense of smell abolished in left nostril and
much diminished in right. Second operation twelve
years after the first. Skull opened by making a flap in
the same way through the old scar. So perfectly had
the bone been reproduced that it was impossible to
determine the limits of the new bone. The bone was
very thick and adherent to the meninges ; a tumour as
large round as a crown piece was found incorporated
with the dura mater — it extended on to the falx. The
dura was divided all round the tumour with the thermo-
cautery and the mass removed. The patient made an
excellent recovery, and seven years after the second
operation was known to be alive. (Fig- loi.)
6. Sarcomaof Outer Aspect of Dura. (Auvert, 1851.) — ■
The patient was a Russian peasant woman, thirty-five
2i6 SOxME POINTS IN THE SURGERY
years old at the time of her death. Eight years
previously she had a severe blow on the right side of
the head. No immediate symptoms of any severity
were observed, and she followed her occupation for a
considerable time without inconvenience. Subsequently
she suffered from headache, increasing in frequency and
severity, the pain being referred to the site of injury.
The attacks terminated with vomiting, which gave some
relief. A soft pulsating tumour appeared at the painful
spot, and increased in four years from the size of a
hazel-nut to that of an orange. The pain became
almost continuous. The patient at this stage consulted
a surgeon, who diagnosed sebaceous cyst, and made an
incision into the tumour ; instead of the pultaceous
matter he expected, blood came out in a full stream, and
the haemorrhage was with difficulty arrested. The
wound did not cicatrise, but rather became larger, and
a bloody, foetid discharge continued to exude from it.
When seen by Auvert the tumour was as large as an
adult head, and its surface was extensively ulcerated.
The patient died six weeks after admission to hospital.
The pia, arachnoid, and dura were intimately adherent
beneath the tumour, and separated it from the cerebral
cortex. The pressure of the growth had to a great
extent obliterated the convolutions of the hemisphere.
(Fig. I02.)
7. Fibro-Sarcoma of Cerebellar Meninges. (Cruveilhier,
1830.) — The patient was twenty-six years old at the
time of her death ; she had had good health until the
age of nineteen years, when she began to suffer from
severe pain in the head at intervals, and gradually
became deaf in the left ear. A twelvemonth later
partial loss of sight was noticed, and after another
year spasm of left side of .face. From this time
OF TUMOUR OF THE BRAIN 217
there was further progressive diminution of sight,
so that three weeks after the first facial spasm
the patient could no longer see her way about. In
a few months there was complete blindness. For
two years her condition remained stationary, the
headache was less and occurred at longer intervals,
appetite was good, and general health satisfactory. The
condition then became worse, the headache increased,
and alternated with severe pain in the left thigh.
Rigidity of the limbs occurred, most marked on the left
side, as well as convulsive movements of the left face.
Smell was now gradually lost. Three months before
death there was complete blindness, and complete loss
of taste and smell, deafness was incomplete. Patient
was able to get up until the last month of life.
Vomiting did not occur until fifteen days before
death.
At the autopsy a hard tumour was found springing
from the posterior surface of the left petrous, to which
it was attached by a stalk which occupied an irregular
cavity in the bone uniting the internal auditory meatus
with the foramen lacerum posticum and with the carotid
canal. " The stalk could be easily separated from the
cavity in which it lay, so that the tumour appeared to
have arisen from the process of dura mater extending
into the internal auditory meatus rather than from the
bone itself." The base of the skull was thinned and
eroded in several places in situations remote from the
tumour, and the brain substance was pressed into these
erosions. The growth had compressed the left half of
the pons and of the bulb and the corresponding cerebellar
peduncles. The sensory root of the fifth nerve was
stretched out into a broad ribbon, and the facial and
auditory nerves were compressed between the brain and
2i8 SOME POINTS IN THE SURGERY
the tumour. The sixth nerve was pushed aside without
damage. The vagus, glosso - pharyngeal, and spinal
accessory nerves were pushed in front of the tumour.
The hypoglossal presented no abnormality. (Fig. 103.)
8. Tumour (f Endothelioma) of Inner Aspect of Dura.
(Cruveilhier, 1830.) — The patient was a woman, aged
forty-five years, a school-mistress, who was seen by
Cruveilhier on 3rd September 1829. The symptoms
observed were frontal headache, inability to walk, weak-
ness of left leg, slow speech, mental enfeeblement, and
involuntary micturition. She died on 3rd October.
Cruveilhier had diagnosed tumour of the frontal lobe,
and had the satisfaction of demonstrating to his class
the tumour in the situation in which he had predicted
that it would be found. (Fig. 104.)
9. Endothelioma of Meninges in Frontal Region.
(Beadles. )^ — The patient was a woman, aged sixty-nine
years, who had been in an asylum for nineteen years.
She was admitted to the asylum with melancholia, and
subsequently suffered from right facial palsy and severe
hemicrania. (Figs. 105 and 106.)
An interesting fact in relation to tumours of the
brain is their presence undiagnosed in the insane. It is,
of course, to be expected that tumours may produce
mental symptoms, and also that tumours of the brain
may arise within the cranium of patients insane from
other causes. Mr. Cecil Beadles has collected a con-
siderable number of brain tumours from autopsies on
insane persons. These cases will shortly be published.
10. Epithelioma of Frontal Region. (Braun of Konigs-
berg, 1892.) — A girl aged fourteen years was admitted to
hospital with an ulcerating carcinoma on the right side
of the forehead ; it extended from the margin of the
orbit to the hairy scalp, and from i centimetre to the
OF TUMOUR OF THE BRAIN 219
left of the middle line to the tip of the right pinna.
The overhanging lower edge concealed, but did not
involve, the eyelids. No enlarged glands were observed.
Brain pulsation was readilv perceptible over the central
area ot the growth. Twelve years previously she had
been severely scalded in the situation of the tumour, and
two years previously she received a blow from a slipper
in the scar ; an ulcer formed which had never healed.
An attempt (in another hospital) had been made to cure
the ulcer by excision and transplantation of skin, but
this failed, and only resulted in extension of the ulcer.
The growth was removed in three stages.
(i) In order to minimise the risk of meningeal infec-
tion, the peripheral portions of the growth were curetted
down to the bone, and the growth cut off where it per-
forated the bone ; the aperture in the bone was as large
as a shilling. The surface was dressed with sublimate
lotion, and, a week later, (2) an incision was made
all round the growth down to the bone ; the superficial
portion ot the bone was removed to within about ^ cm.
of the aperture through which the growth passed ; here
the whole thickness of the bone was removed. The
wound in the soft parts measured ii^ cm. from above
downwards, and 10^ cm. from right to left. Smart
bleeding from the middle meningeal artery, in its bony
canal, led to the operation being interrupted at this
stage. (3) Twelve days later the opening in the bone
was enlarged, the lateral aspect of the superior longi-
tudinal sinus was wounded, but the bleeding was easily
controlled. Bone was removed until the dura was ex-
posed over an area of 6^ cm. square ; round the margin
of this area the dura was incised, the cut edges raised up
and turned over the growth. The growth was firmly
adherent to, and apparently incorporated with, the brain.
220 SOME POINTS IN THE SURGERY
The vessels in the pia were Kgatured all round the
growth, and the growth cut away with a part of the
frontal lobe ^ cm. thick, 3^ cm. from above down-
wards, and 4 cm. from right to left. Wound left open
and dressed with iodoform gauze. Violent anaesthetic
vomiting was the only immediate after - symptom.
Hernia cerebri four days later. This attained a con-
siderable size, and did not begin to diminish for a
month. Six weeks after the removal of the tumour
some induration was noticed about the granulations
at the spot where the middle meningeal haemorrhage
had taken place, bone was cut away, and the indurated
tissue removed by the thermo- cautery, together with
the underlying dura and a layer of brain substance.
Microscopical examination confirmed the diagnosis of
recurrence.
Two months afterwards another portion, in which
recurrence was suspected, was excised, but histological
examination showed no evidence of growth.
When there had been nothing to lead to the suspicion
of recurrence for a whole month, the wound was par-
tially closed' by a plastic operation, after the site of the
hernia cerebri had been freshened with the thermo-
cautery, and the closure completed subsequently by skin
grafting.
Eleven months after the first operation healing was
complete. No cerebral symptoms. (Fig- 109.)
II. Epithelioma of Frontal Region, (von Mikulicz.)
— A married woman, aged fifty years, was admitted to
hospital with a large, malignant ulcer over the right
half of the frontal bone. The surface bled easily and
was partly covered with crusts. It was made up of a
number of separate, rounded, warty masses, which in
places had a glistening surface. In the centre of many
OF TUMOUR OF THE BRAIN 221
of the masses was an easily removed epidermis plug.
The greater part of the upper eyehd was destroyed by
the ulcer. There was no optic neuritis, nor any affec-
tion of cranial nerves. No enlarged glands were seen.
Five years previously a small ulcer had been noticed,
which never healed, but increased in size, very slowly at
first, but rapidly during the six months before admission.
At the operation the growth was found to have per-
forated the trontal bone and involved the dura. The
growth was removed, together with a piece of the
frontal bone as large as a five-shilling piece, and a
considerable portion of the zygoma. The eyelid was
so extensively involved that it was thought better to
sacrifice the eyeball. There were no meningeal
adhesions, the exposed pia looked normal. The whole
area of the bone defect and the greater part of the
skin wound was covered in by a flap which included
the outer table of the skull, cut from the forehead
and hairy scalp. The flap was so planned that its
attached base was downwards. The raw surface ot
the bone in the flap rested against the pia. The flap
was held in place by a few silver sutures, and the surface
left in raising it allowed to granulate and afterwards
grafted. The flap united readily. A small recurrence
took place on the cheek three months later. When the
paper was read (eight months after the first operation)
only the outer angle of the wound was still granulating.
(Fig. no.)
222 SOME POINTS IN THE SURGERY
Fig. 96.
Fig. 97.
Figs. 96 and 97. — Parosteal round-celled sarcoma of the squama.
Fig. 96. — Before operation.
Fig. 97. — -Recurrence five months after operation.
■
1
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w^
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4r^
^''
n
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> -^^^H
1
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Fig. 98. — Periosteal sarcoma of squama.
The deviation of the eyes is not due to disease.
OF TUMOUR OF THE BRAIN 223
Fig. 99. — Cavernous angeioma (without sarcoma cells) of os frontis projecting
backwards into skull- cavity and compressing frontal lobe. (Zajaczkowski of
Poland. From Sawicki's article in Chipault, ii.)
The figure is taken from a photograph after operation.
Fig. 100. — Sarcoma of orbital part of os frontis displacing dura and brain.
(Preindlsberger of Serajevo in Bosnia. Chipault^ ii.)
The figure is taken from a photograph after operation.
224 SOME POINTS IN THE SURGERY
Fig. ioi. Sarcoma of outer aspect of dura mater compressing left frontal lobe.
(Durante. Roncali's article in Chipault, iii.)
The figures represent the parts removed at the second operation —
[a) the growth still attached to the bone ;
(b) the bone with the growth removed, to show how perfectly it had been
reproduced.
Fig. I02. — Sarcoma of outer aspect of dura. (Auvert.)
OF TUMOUR OF THE BRAIN 225
Fig. 103. — Fibrosarcoma of cerebellar meninges. (Cruveilhier.)
The upper figure represents the cavity in the petrous, in which the stalk of the
growth was lodged. The lower figure shows the growth attached to the petrous
and some erosions in other parts of the base of the skull.
Q
226 SOME POINTS IN THE SURGERY
//
Fig. IC4. — Tumour (? endothelioma) of meninges in frontal region. (Cruveilhier.)
The figure shows the tumour adherent to the inner aspect of the dura, and the
depression in the frontal lobe in which it was lodged.
OF TUMOUR OF THE BRAIN 227
Fig. io<.
m
-
.
0
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^J:
''■^
«5
fe
'■]\, s
1
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Fig. 106.
Figs. 105 and 106. — Endothelioma of meninges in frontal region. (Beadles.)
Fig. 105. — Photograph of tumour and depression in frontal lobe in which it was
lodged.
Fig. 106. — Microscopical section of tumour.
228 SOME POINTS IN THE SURGERY
1
^
/■ ' *■•
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-;^ ^^
^ "'5
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-. /*;-•.
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Fig. 107. — Sarcoma ossis frontalis before and after operation. (From von Berg
mann's article in the German System of Practical Surgery, American Edition.)
Fig. 108. — Destruction of skull by malignant disease. (Lebert, 1859.)
T/ie upper figure represents the skull of a case which was observed in 1764. The
patient was a man 21 years of age. When admitted to hospital he had a tumour
the size of his head projecting from the left side of the skull. In four months
death occurred. The growth was a sarcoma of the dura mater. The temporal
bone was destroyed.
The loiuer figures represent a skull which is in the Musee Dupuytren. Lebert
does not give the history of the case.
OF TUMOUR OF THE BRAIN 229
Fig. 109. — Epithelioma of frontal region. (Braiin of Konigsberg.)
Fig. 1 10. — Carcinoma of frontal region, (von Mikulicz, reported by Tietze.)
The figures show the appearance of patient before and after operation, and the
mass removed.
230 SOME POINTS IN THE SURGERY
Tumours of the Cerebellum
As I referred at some length in the second
lecture to cases illustrating the symptoms of
the temporo-sphenoidal lobe, I propose in this
lecture to illustrate the application of localising
symptoms to diagnosis by discussing the signs
of cerebellar disease and relating some illus-
trative cases. Tumours which are capable of
enucleation are more frequently met with below
than above the tentorium. Tumours in the
occipital fossa are of various kinds. The
common varieties are fibroma, myxo-fibroma,
fibro-sarcoma, endothelioma, sarcoma, glioma,
simple cyst, and solitary tubercle. The great
morbid anatomists of the first half of the nine-
teenth century were familiar with meningeal
tumours, which they described under the name
" fibro-plastic tumour," and they also figure
what we now know as the solitary tubercular
tumour.
Diagnostic Symptoms of Cerebellar Tumour. —
Most observers agree on the main facts, but
there is a conflict of opinion on the localising
significance of some symptoms, such as the
side to which the patient tends to fall. This
conflict of opinion may be explained in some
cases by the symptoms caused by a tumour
OF TUMOUR OF THE BRAIN 231
differing according to whether it is intra- or
extra-cerebellar, or whether its effects are irri-
tative or destructive. Some of the signs and
symptoms are of general while others are of
regional significance. It may at once be said
that certain signs, when present, make the
regional diagnosis easy, when such signs are
absent the problem of localisation may be in-
solvable. The patient commonly complains of
headache, vomiting, vertigo, unsteadiness of
movement, and dimness of vision. The head-
ache is most often occipital, but is sometimes
frontal, and occasionally, though rarely, limited
to the contra-lateral frontal side. It is severe,
may be insupportable, and the paroxysms are
often associated with severe vomiting. Vertigo
is an early sign, comes on with change of
position, is associated with a feeling of utter
faintness, and causes a tendency to fall inde-
pendently of titubation. Recently I saw with
Dr. Charles Green a woman, aged thirty years,
who had some signs of left cerebellar tumour,
she became intensely giddy on suddenly being
rotated towards the left. The direction of the
subjective sensation of movement differs accord-
ing to whether the tumour is intra- or extra-
cerebellar. In extra-cerebellar tumour the
subjective rotation of self is to the side of the
232 SOME POINTS IN THE SURGERY
lesion, in intra-cerebellar tumour of the lateral
hemisphere it is away from the lesion. Louis
ToUemer concludes his remarks on cerebellar
vertigo by saying that its chief characteristics
are constancy and intensity. Attacks of vertigo
often occur suddenly, like epileptic fits." Dis-
turbances of equilibrium are not always accom-
panied by the subjective sensation of giddiness.
Duret points out that the vertigo of Meniere's
disease can be usually distinguished without
difficulty from that caused by tumours in the
occipital fossa, or tumours involving any part
of the vestibular tract, by the presence in the
latter of other signs of tumour, and by certain
peculiarities in the seizures. The mental state
is normal or only affected later as a con-
secutive phenomenon. Sensation is intact. In
children the occipital region may bulge. Tender-
ness on percussion over the occipital region is
rare and is suggestive of a superficial lesion ;
in an individual case it may be present some-
times, but not at others.
A woman, aged twenty-seven years, under the
care of Dr. Ferrier, had weakness of left external
rectus, slight weakness of left side of face, inco-
ordination of movement of left limbs, and slow
and deliberate nystagmus, more marked towards
the left than towards the right. When her
OF TUMOUR OF THE BRAIN 233
feet were placed close together she fell back-
wards and to the left. There was tenderness
on percussion over the whole occipital region,
but especially on the left side. I removed a
large glioma from the left cerebellar hemisphere.
The deep reflexes may either be diminished
or exaggerated ; in either event the modification
is on the side of the lesion in lateral cerebellar
tumour. In a tumour of the cerebello-pontine
angle the exaggeration is likely to be due to
pressure on the crus, and will then be on the
contra- lateral side. The attitude of the head is
in some cases characteristic. Batten writes : —
" When standing or sitting, the head is held
with the ear approximated to the shoulder on
the side opposite to the tumour. The face is
turned to the side of the lesion and the chin
elevated." In experimental ablation of the
lateral lobe the opposite position is assumed.
This position would naturally be adopted to
relax the wound. Also the head may be re-
tracted or the chin depressed on the chest ;
the anterior or the posterior part of the vermis
is then probably involved. The dimness of
vision is due to optic neuritis^ which is an early
sign, is very pronounced, and is most intense on
the side of the lesion. Failure of sight is some-
times very rapid.
234 SOME POINTS IN THE SURGERY
Certain remarkable disturbances of equilibrium
and of movement may be observed. On stand-
FiG. III. — Photograph of a child, aged 5 years, showing position of head assumed
in a lesion of the right lateral lobe of the cerebellum. (Batten.)
" When standing or sitting she held her head to one side, so that her left ear was
approximated to the left shoulder ; her face was turned to the right, and the chin
was slightly elevated ; there was a slight spinal curve, with the concavity to the
left."
ing the feet are widely separated, the abduction
being greatest on the homo-lateral side. Un-
OF TUxMOUR OF THE BRAIN 235
steadiness may be so great as to prevent standing.
Romberg's sign may or may not be present.
When present the tendency to fall is to the side
of the lesion when this is in the lateral lobe, and
backwards when in the vermis. When walking
Fig. iiz.^Child with right cerebellar tumour (solitary tubercle). (Louis Toilemer.)
A, position when standing, right thigh abducted ; B, position when sitting, right
thigh abducted.
the patient keeps the feet wide apart, staggers,
and, instead of progressing forward in a straight
line, follows a zig-zag course ; the deviation from
the straight line is more marked towards the
side of the lesion. The patient is unable to
turn sharply. The gait has been compared to
236 SOME POINTS IN THE SURGERY
that of a child when first learning to walk.
Ataxy of the limbs is manifested by want of
steadiness and precision on executing voluntary
movements, particularly in rapid succession.
For example, alternate movements of pronation
and supination, which the normal individual
can execute with great rapidity, are less rapidly
and less precisely performed by the subjects of
cerebellar disease. This disturbance of the
power of repeating movements in rapid suc-
cession is termed diadocokinesis. Again, if the
thigh be flexed on the abdomen and the leg
on the thigh, and the patient be then asked to
extend the limb, the movement will not, as in
the normal individual, be performed as a whole,
but the two segments of the limb will be ex-
tended separately. This want of correspondence
in time and energy of the movements of groups
of muscles which should act together is termed
asynergia. These phenomena are most marked
in the homo-lateral limbs, but occur on both
sides, particularly when the vermis is involved.
In a male child, aged six years, under the
care of Dr. Risien Russell, who was found to
have a tumour in the vermis, it was noted that
the muscles were well developed but deficient
in tone. The strength was fair and about equal
on the two sides. Co-ordination was impaired
OF TUMOUR OF THE BRAIN 237
on both sides, rather more on the left. There
was no tremor when at rest. He stood with
considerable lordosis from weakness of spinal
muscles, and kept his feet wide apart. He
reeled and staggered to both sides, but more
frequently to the left. When his feet were
placed together he tended to fall backwards
and to the left. There was weakness of
both external recti. In bed the head was
retracted. The left occipital region bulged.
The tumour in this case was a glioma ; it
occupied the central portion of the vermis, and
measured 3|- cm. across. I operated, but failed
to remove the tumour.
Bruce says : — " Lesions situated in the lateral
lobes may produce no disturbance of equilibrium
provided they are situated entirely external to
the intra-cerebellar paths of the upper and lower
peduncles and of the nucleus dentatus (area of
possible latency). If, however, these structures
are interfered with, either by pressure or by
direct involvement, then the characteristic symp-
toms of cerebellar disease will be produced, and
will depend in their character and amount on
the nature and extent of this interference. If
the cerebello-vestibular tract or Deiter's nucleus
be injured, then the usual stimuli will not pass
either to the anterior cornua of the cord or to
238 SOME POINTS IN THE SURGERY
the sixth or third nucleus. Hence may result
the weakness of the same side, the tendency to
fall to that side, the tendency of both eyes to
be directed to the opposite side, and the lateral
nystagmus which occurs, especially when the
eyes are directed towards the same."
Titubation and disturbance of orientation may
be observed in lesions of the vestibular nerve
anywhere between the peripheral termination
and the cortical representation in the posterior
two-thirds of the temporal lobe. These symp-
toms, therefore, are not diagnostic of cerebellar
lesion. Horsley, for example, reports a case
diagnosed as one of injury to the middle
peduncle of the cerebellum, the crus, the optic
tract, and the temporal lobe, in which there were
forced movements, vertigo, auditory amnesia,
and hemianopsia. As the cortical terminations
of the vestibular nerve are in the temporal lobe,
it is easy to understand that in tumour or
injury involving these fibres near their cortical
distribution there may be, in addition to tituba-
tion and disturbance of orientation, hemianopsia,
forced movements, and disturbance of the senses
of hearing, smell, and taste. Forced rotation only
occurs in lesions of nervous tissue proximal to
the internal ear, not in internal or middle
ear disease. Forced movements in cerebellar
OF TUMOUR OF THE BRAIN 239
tumour seem more common after operation than
before.
One of the most striking signs in some cases
of tumour involving the cerebellar hemisphere
is weakness and loss of tone oj the ??mscies of the
homo-lateral limbs. An early view of Luciani
was that this atonia was due to the cuttino- off
o
of the reinforcing influence of the lateral lobe
of the cerebellum from the opposite cerebral
hemisphere. The absence of this reinforcing
influence would make itself felt via the pyra-
midal tracts, hence the weakness of the homo-
lateral upper limb, and of both lower limbs,
and the conjugate deviation of the eyes to the
opposite side. Pagano's experiments are of
great interest. He used the excitation method ;
his chief conclusions are : — i. Stimulation of one
lateral lobe of the cerebellum produces motor
phenomena, varying in intensity from simple
contraction of groups of muscles in a limb, caus-
ing it to assume fixed attitudes, up to violent
convulsions. The muscles affected are the
homo-lateral ones, and there are definite cere-
bellar zones corresponding to groups of muscles.
There is also rotation of the body on its longi-
tudinal axis, which occurs constantly from the
side of excitation towards the other side. 2.
Movements produced by cerebellar excitations are
240 SOME POINTS IN THE SURGERY
accomplished by intermediation of the cerebral
cortex, because extirpation of the contra-lateral
motor area abolishes the localised muscular con-
tractions of the limbs on the same side, and the
rotation of the body occurs in the contrary
direction, showing that the action of the cere-
bellum, though preponderating on the homo-
lateral, acts also on the contra-lateral muscles
through the corresponding motor cortex. Com-
plete extirpation of both motor cerebral areas
abolishes completely the motor phenomena. 3.
Stimulation of the anterior part of the vermis
causes the head to look upwards and induces an
irresistible tendency to fall backwards. 4.
Stimulation of the posterior part of the vermis
causes an irresistible tendency to fall forward —
the head being drawn strongly downwards on
the chest. Pagano says that the cerebellum has
an energising action on the cerebro - spinal
centres, that no organ is innervated directly
from the cerebellum, and that the asthenia of
the homo-lateral limbs produced by the ablation
experiments of Luciani by no means contradicts,
but confirms his results.
We may accept the results of Pagano's
experiments, but need not adopt the theoretical
conclusions based thereon. What, then, is the
function of the cerebellum ? Louis Tollemer
OF TUMOUR OF THE BRAIN 241
writes "that the cerebellar hemisphere regu-
lates, suppresses, or excites at the appropriate time
the nervous impulses which give rise to muscular
contraction." In my view it neither reinforces
nor energises the cerebral cortex. Its energy,
obtained from the common source of supply, the
blood, is required for the exercise of its own
functions. The cerebellum is the reflex centre
of the sensori-motor system concerned in equi-
libration, co-ordination of muscular movement,
and the sense of orientation. It receives im-
pressions from the vestibular apparatus, the eyes,
and (through the spinal cord) the muscles, and
probably the skin. From these impressions it
elaborates efferent impulses, which reach the
central nuclei and the cerebral cortex, and
through them the muscular apparatus. Static
equilibrium is maintained unconsciously, or at
least subconsciously. The reflex arc passes
through the cerebellum, the red nucleus, the
corpora quadrigemina, the nucleus of Deiters,
the nucleus of Bechterew, and the nuclei in the
pons. " In all movements and attitudes the
influence of the cerebellum is manifested by
variations in muscular tonus, which regulates
the extent and the force (and the time) of these
movements. Thus, when an animal, a dog,
raises its front paw, not only must the cortical
242 SOME POINTS IN THE SURGERY
motor centres come into action in order to com-
mand and bring about the movement by way of
the pyramidal tract, but a particular state of
tonicity in the neighbouring muscles, and,
indeed, in the whole trunk, is essential during
the whole time that the movement is continued
in order to assure its smoothness and precision.
The cerebral cortex sends impulses by way of
the crus, the pons, and the middle cerebellar
peduncle to the cerebellar cortex simultaneously
with those that it sends to the cord. The
cerebellar cortex, through its efferent fibres and
its central ganglia, supplies the tonus necessary
to the corresponding muscular apparatus and to
the trunk itself. The brain is kept informed of
all the modifications of the muscular apparatus
by the efi^erent cerebellar fibres which pass to the
red nucleus and the optic thalamus by way of the
cerebellar superior peduncles, and thus at every
moment, at every period of the movement,
equilibrium is maintained. But let there be
an unilateral lesion of the cerebellum, the
muscular tonus furnished by this side of the
cerebellum will be wanting from the homo-
lateral muscles, while the contra-lateral muscles
will remain abundantly provided for ; hence
incurvation of the trunk, loss of equilibrium,
oscillation, and fall towards the side of the
OF TUMOUR OF THE BRAIN 243
lesion" (Duret). The conductor of an orchestra
does not play any instrument nor energise any
performer, but it is through his influence that
the work of each individual performer is exactly
adapted to that of every other. Without such
guidance, though all the parts might be played
correctly as parts, there would be " asynergia,"
and the effect on the audience would differ from
that intended by the composer. Muscular
movement is in some such way co-ordinated
through the cerebellum.
Operations on man and ablation experiments
on brutes show that weakness occurs in the
homo-lateral upper extremity on removal of the
cerebellar hemisphere. In a case of mine, already
referred to, no tumour was found, but the intra-
cranial pressure was so great that the healthy
lobe of the cerebellum was pushed through the
dural opening and much of it was lost by
sloughing. The patient recovered, was com-
pletely relieved of his headache and vomiting,
but for some months his left arm was so weak
as to be quite useless. Masnata relates the
following case: — A man, aged thirty -eight
years, whose sight was much impaired from old
standing corneal disease, fell backwards and was
brought home unconscious ; in the left occipital
region were two scalp wounds and a large
244 SOME POINTS IN THE SURGERY
hsematoma. The symptoms of cerebral com-
motion subsided, but there was bi-lateral facial
paralysis and complete immobility of the eye-
balls, with squint, clonic spasm of the right
limbs, high temperature, and feeble pulse. The
patient was drowsy, with intervals of agitation ;
voluntary movements were slowly and hesi-
tatingly performed ; there was some rigidity of
muscles of neck. Operation on the eighth day ;
fracture of occipital bone with a large splinter.
On removing the splinter a black pultaceous
mass escaped ; the removal of this slough, which
involved a great part of the left cerebellar
hemisphere, was completed with the curette.
Immediately after the operation the pulse im-
proved, the temperature fell, and the facial
paralysis disappeared. The patient recovered,
but for many months was quite unable to stand
without support owing to weakness of the limbs
on the side of the lesion ; he tended to fall
backwards and towards the side of the lesion.
Durante, in removing a growth involving the
antero - superior part of the right cerebellar
hemisphere, was constrained to destroy the
whole of the corresponding lobe. In the
thirteen hours which preceded the patient's
death he observed very pronounced asthenia and
atonia of the muscles of the homo-lateral limbs.
OF TUMOUR OF THE BRAIN 245
a high temperature, rapid pulse, exaggeration
of the patellar reflexes, and a strong tendency to
turn in bed so as to lie on the side of the lesion.
Roncali remarks that the cases hitherto observed
of surgical removal of one cerebellar hemisphere
confirm the experimental observation that the
affection of the limbs is on the side of the lesion,
but that in cases of tumour the limbs on both
sides are almost always affected ; this he attri-
butes to compression, a view confirmed by some
experiments conducted by him in order to eluci-
date the effect of compression as distinct from
ablation of one cerebellar hemisphere.
The asthenia is often marked in the muscles
of the trunk, especially the spinal muscles, and
this is probably most obvious when the vermis
is involved. Holmes and Grainger Stewart
write: "The character of the weakness, the
absence of any organic rigidity, and the normal
state of the superficial reflexes, are strongly against
any interference with the pyramidal tracts."
In addition to asthenia or weakness there is
loss of tone of the muscles of the homo-lateral
limbs, causing them to be flaccid and the limbs
to assume unusual positions. Spasticity of the
limbs may be present, and is an indication, as
Mills points out, of an irritative, not a destructive
lesion. Astasia may also be present. " A dog
246 SOME POINTS IN THE SURGERY
from whom half the cerebellum has been
removed, when lying on the ground differs from
a normal dog only by a slight uninterrupted
trembling of the head, which in the circum-
stances is the only part of the body not supported.
If the dog stands up the trembling extends
to the trunk, which wobbles slightly either
transversely or obliquely. When it walks slowly,
writes Luciani, the same phenomenon becomes
exaggerated in the muscles of the homo-lateral
side, especially those of the limbs and of the spinal
column. We notice, indeed, that the movements
of the limbs of the operated side are wanting in
smoothness and continuity, and that the verte-
bral column shows a characteristic want of
firmness and rigidity which certainly depends
upon the fact that muscular contractions are
irregularly performed, as always happens when the
perfect harmony of the elementary contractions
upon which muscular action depends is dis-
turbed. And it is to this absence of the proper
blending of muscular movements that clinicians
have given the name of titubation or uncertainty
of voluntary movements, because the observer
gets the impression that the subject hesitates to
come to a decision, or experiences delay in trans-
mitting the requisite impulses to his muscles.
This hesitation or uncertainty of movements,
OF TUMOUR OF THE BRAIN 247
manifest enough when the animal walks slowly,
disappears when it spontaneously or under com-
pulsion quickens its pace" (Roncali). Quite
similar phenomena have been observed in man.
Optic neuritis has already been mentioned. As
failure of sight from this cause is so frequent
Fig. 1 13. — Skew deviation of the eyes taken a few weeks after removal of tumour from
the left lateral lobe of the cerebellum. (Grainger Stewart and Gordon Holmes.)
The patient was a man, aged 27, and the tumour was a gumma which Sir Victor
Horsley removed. The skew deviation occurred immediately after the operation,
the left eye being directed downwards and inwards, and the right outwards and
slightly upwards ; it persisted for two months.
and occurs so early, it should be included in the
syndrome of cerebellar tumour. The ocular
symptoms are of importance. There may be
conjugate deviation of eyes to the opposite side,
or skew deviation (Majendie, Russell) especially
after operation. Lateral nystagmus is common,
248 SOME POINTS IN THE SURGERY
the jerks being towards the side of the lesion.
Mills says, " We have not been able as yet to
make any inference of localising value from a
study of cerebellar nystagmus, although it would
seem probable that in a case of destructive lesion
affecting the cerebello - vestibular tract, the
nystagmus would be greater when the eyes were
directed toward the side of the tumour." Other
cranial nerves may be involved, especially in
tumours of the cerebello-pontine angle. Sixth
nerve paralysis, deafness and tinnitus, paresis of
face, trigeminal neuralgia, and anesthesia, weak-
ness of the palate, difficulty in swallowing, and
deviation of the tongue, have all been met with.
In lesions of the vermis, as seen in Pagano's
experiments, rotation occurs around a horizontal
axis : in lesions of the lateral lobe around a
vertical axis. In some instances both of abscess
and tumour of the hemisphere, as in Russell's
experimental ablations, the patient lies on the
healthy side^ so that the side of the face corre-
sponding to the side of the lesion is uppermost.
In a case of mine, minutely described by Holmes
and Grainger Stewart, fits were observed after
operation with rotation of the body towards the
healthy side. Dr. Jackson has described tonic
fits in tumours of the vermis, and Dana last
year published a paper " On the Syndrome
OF TUMOUR OF THE BRAIN 249
(Cerebellar Fits) characteristic of Cerebellar
Tumours " ; these were associated with tinnitus,
vertigo, forced movements, loss of consciousness,
and in some cases tonic spasms.
I cannot close this short account without
referring; to mv indebtedness to the admirable
symposium on cerebellar tumours in the Neii'
Tork Medical Journal^ 19055 by various dis-
tinguished American authors, and to the paper
by two of my junior colleagues. Dr. Gordon
Holmes and Dr. Grainger Stewart, in Brain^
1904.
The following cases illustrate the observa-
tions about symptoms : —
Case I. — A feeble male child, aged 3|- years, was
admitted in September 1899, under Dr. Lees, into the
Hospital for Sick Children, Great Ormond Street. He
had been ailing about six weeks. For three weeks the
symptoms had been headache, vomiting, staggering
gait, and lateral nystagmus. There had been no fits.
The headache was occipital. On admission. — Pupils
equal ; double optic neuritis ; slight lateral nystagmus.
Right cerebellar fossa bulging ; gait ataxic ; mental
action slow. No paralysis. Speech natural. October
^th. — Frequent vomiting ; slight twitching movements
of right arm and hand. Reflexes have varied from
time to time. October 6th. — Bone over right occipital
fossa removed. October ^th. — Encapsuled tumour
enucleated from the middle of the right cerebellar
hemisphere. It weighed 507 grains. Patient never
250 SOME POINTS IN THE SURGERY
really rallied from the operation, and died on October
15th. No autopsy allowed.
Fig. 114.- — Bulging right occipital fossa in a child 3^ years. (Lees and Ballance.)
The illustration is a photograph of a cast.
Note. — The bulging occipital fossa clenched the
diagnosis.
Case 2. — Male, aged 6|-. Admitted May 26th, 1905,
into the Great Ormond Street Hospital under my care.
In October 1904 he received a blow behind the left ear
from which resulted headache that kept him awake all
that night. After Christmas he began to have head-
ache and vomiting at intervals. The vomiting occurred
in the night or early morning, and did not seem to have
any relation to taking food. About the same time the
left eye was noticed to squint. Six weeks before
OF TUMOUR OF THE BRAIN 251
admission the child had a bad fall, and was uncon-
scious. Since then he has been giddy, unable to walk
without staggering, and his pupils have become dilated.
Family history. — Both parents are well ; they have
five other living children ; one died at the age of nine
months from "water on the brain and convulsions."
The mother has had no miscarriage, and there is
nothing to suggest tubercle or syphilis. Previous
history. — Satisfactory. On admission. — A well-nourished
boy, with a large head and bulging forehead. The
cerebellar region seems more prominent on the right
side. No tenderness on pressure or on percussion of
either cerebellar region. Sensation normal. Inco-
ordination to an equal extent in both arms. Marked
inco-ordination in both legs when walking. The gait
is very unsteady, the feet being placed wide apart, and
moved with uncertainty. While standing with the feet
close together he tends to fall indifferently to either
side. The muscles are not flabby, and their power
does not seem diminished. Though he can only stand
with great difficulty, he can walk quickly or run, but
always tends, whether walking or running, to deviate
to the right. The attitude of the head reminded me of
Batten's paper ; the right ear was approximated to the
right shoulder ; the face was turned towards the left,
and the chin elevated. Reflexes. — Knee-jerks increased
and equal ; no patellar clonus. Plantar reflex is
extensor on left side. Tendon reflexes in arms not
increased. Eyes. — Well marked left internal squint.
No nystagmus. Both pupils widely dilated, but equal.
They react equally, sluggishly, and incompletely to
strong light, but not to accommodation. Optic
neuritis on both sides ; more marked on left. Vision
so much impaired that he cannot count fingers at three
252 SOME POINTS IN THE SURGERY
feet. Ears. — Normal. Hearing good. Voice rather
drawling. Other systems normal.
Operation — First Stage., June i^th. — The bone over
the right occipital region was removed ; it was very
Fig. 115. — Simple cyst of left cerebellar hemisphere.
Boy, aged 6^ years. Patient did not survive second operation.
thin. The dura bulged strongly, but appeared healthy.
Second Stage, June 2^th. — -The dura was incised, and
the right half of the cerebellum was examined ; nothing
abnormal was found. The child bore the operation
OF TUMOUR OF THE BRAIN 253
well, and was only slightly sick afterwards. Progress. —
On July 5th the child vomited again. The flap bulged
considerably. The squint had disappeared, but there
was marked nystagmus. Inco-ordination was worse ;
the voice was more drawling than before, and all sense
ot tune was lost. Second Operation — First Stage., J^b
6th. — Bone removed over left cerebellar region, leaving
a bridge in the middle line. The dura looked healthy.
Progress. — On July 8th vomiting began, and con-
tinued till the next day, when the child died. The
second stage of the operation was not performed.
Autopsy. — Large simple cyst found in left lobe of
cerebellum.
Remarks. — Captain Mahan, the eminent naval his-
torian, explains Sir Robert Calder's failure to bring
Villeneuve's squadron to decisive action by his having
made to himself a "picture," and allowed the impres-
sion produced by it to blind his mind to the facts of
the situation — an error against which Napoleon used to
caution his generals. I painted a mental picture in this
case of a tumour beneath a bulging occipital fossa, and
allowed it to blind me to the true interpretation of the
other symptoms. Many striking examples of similar
errors are to be found in surgical records. On
examining the case the slight enlargement of the right
occipital region made an undue impression on my mind.
This was increased by the recollection of Case i, and
by the fact that there was another child with marked
bulging of the occipital fossa (Case 3) in the ward at
the time. In mitigation of the mistake I may say that
all my friends who examined the case rather inclined to
the view that the tumour was on the right side. On
reflection it is clear that the mistake might have been
avoided. The points in favour of a left-sided tumour
254 SOME POINTS IN THE SURGERY
were — (i) Site of injury, (2) the attitude of the head,
(3) the greater intensity of the optic neuritis on the left
side, (4) the paralysis of left sixth nerve, (5) ankle
clonus and Babinski reflex present on the left side only.
Case 3. — A male child, aged four years and ten
months, was admitted into the Hospital for Sick Children,
Great Ormond Street, under the care of Dr. Colman, on
May 4th, 1905. Three months previously the child
began to suffer from pains in the head, chiefly at the
back, accompanied by vomiting. The child slept day and
night in the intervals between the attacks of pain. The
head was held over to the left side. Family history. —
Both parents are living and well. They have two
other children living — an older, who is healthy, and a
younger, who has an aural discharge. One child died
from injuries received during forceps delivery. The
mother had two miscarriages — one at the third, and the
other at the fourth month previously to the birth of her
first child. Previous health. — Full time ; difficult
instrumental labour. Breast-fed for seven months.
Had. whooping-cough at nine months, and has not
seemed quite the same since. Three years ago he had
pains in the head, but no vomiting. There have been
slight pains in the head ever since, for which he has
been attending the Out-Patient Department. When
eighteen months old the mother thought he was weak
in the left arm. Never known to have had a rash or
snuffles. On admission. — Child anasmic and flabby.
The cerebellar region seems to bulge unduly on both
sides, but is much more prominent on the left. No
tenderness on pressure or on percussion. There is a
scar on the right arm. Sensation normal. The left
upper limb is weaker than the right. No difference in
OF TUMOUR OF THE BRAIN 255
the lower limbs. There is manifest inco-ordination in
the movements of the left arm, slight inco-ordination
in those of the right, but none in moving the legs.
The gait is unsteady, the feet being placed wide apart,
and the arms kept in constant motion to maintain
Fig. I 16.
Fig. 1 17.
Fig. 116. — Photograph of cast of back of head, showing bulging left occipital fossa.
(Colman and Ballance.)
Fig. 117. — Illustration of solitary tubercle removed from left occipital fossa with
success. X Site of attachment to tentorium.
The patient was 4 years and 10 months old. The tumour measured 1.82 x 1.73 x 2.2
inches, and weighed i^ oz.
equilibrium. Fie falls to either side indifferently.
Epigastric reflex increased on the right side. Cremas-
teric marked, and equal. Knee-jerks equal, and not
increased. Ankle clonus not present. Plantar reflex
normal on the right side, slightly extensor on the left.
Slight internal squint on left side ; very slight nystagmus
on looking to the right. Pupils rather dilated ; react
256 SOME POINTS IN THE SURGERY
both to light and accommodation. No optic neuritis.
Ears and voice normal. Other systems normal. Since
the time of admission he has been treated with pot. iod.
without improvement.
Operation — First Stage, June 2ind. — Bone removed
over the left cerebellar region. The bone was deficient
at one spot, and was so thin that the lateral sinus could
be seen through it. The bone was removed as high as
the horizontal and as far forward as the vertical
portion of the sigmoid sinus. Through the thin
bulging dura the cerebellar convolutions could be plainly
seen. At one place below the sinus the convolutions
were replaced by a more uniform appearance. Second
Stage, June i\th. — The flap of soft tissues was thrown
down ; no convolutions were seen through the dura ;
the exposed area had now a clear, transparent appear-
ance. A flap was cut in the dura, and clear oedematous
brain tissue bulged into the wound. A tumour was
felt, and slowly enucleated. It was a solitary
tubercle, occupying almost the whole of the interior of
the left lobe of the cerebellum, extending as far as the
middle line and as deeply as the pons, and was attached
to the under surface of the tentorium just internal to
the lateral sinus. The child stood the operation well.
Progress — July 20th. — There has been occasional
vomiting and rise of temperature since operation.
Wound now soundly healed. The voice, which was
rather drawling after the operation, has now much
improved. August \th. — Inco-ordination is still mani-
fest in both arms ; nystagmus, which was worse just
after the operation, is now better, but still present.
Left plantar reflex no longer extensor. September %th.
— Is much brighter and stronger ; has learnt to walk.
The nystagmus and inco-ordination are both improved.
OF TUMOUR OF THE BRAIN 257
November ^th. — Has been at a convalescent home
since last note ; is now much stronger. The inco-
ordination of the right arm has improved ; that of the
left is the same. He walks with a stiff gait. September
1906. — Child quite well.
Case 4. — Female, aged seven years and ten months.
Fig. 118. Fig. 119.
Figs. 118, 119. — Case 3. Dr. Colman's case fifteen months after operation.
The scalp flap is concave.
Admitted to the Hospital for Sick Children under
Dr. Garrod, May 29th, 1905. Her illness commenced
in the preceding January with vomiting, which at first
occurred every morning, and has been repeated at
intervals ever since. All the time she has had attacks
of pain in the back of her head so severe as to cause
her to cry out. She would sometimes grasp her throat
and say she felt as if she were being strangled. She
walks with a stiff gait and has wasted a good deal.
s
258 SOME POINTS IN THE SURGERY
Her father and mother are well ; she is the third
of five children, one of whom has had post-diphtheritic
paralysis. No history of tubercle in family.
On admission. — -Well-nourished child ; complains of
pain at the back of the head. No tenderness of scalp.
No signs of rickets or syphilis. No fixed attitude of
head. The skull is asymmetrical, but the cerebellar
regions seem equal. Sensation normal. No loss of
power in the limbs. Muscles in good condition. No
inco-ordination. Superficial reflexes normal. Knee-
jerks present and equal. Both plantar reflexes are flexor.
The gait is very slightly stiff, but there is no tendency
to fall to either side. Optic neuritis in both eyes,
more marked in the right. Hearing is not quite so
good on the right side. No paralysis of face, eye, or
speech muscles. Other systems normal.
June I'jth. — The optic neuritis has increased in both
eyes ; there is a small retinal haemorrhage on both sides.
Attacks of headache and vomiting have been frequent.
Operation — First Stage^ June i()th. — A scalp flap
was thrown down over the right cerebellar region.
The bone, which was very thin, was removed, as in
the two previous cases. The cerebellum could be seen
through the thin dura, and looked healthy. There
was considerable intra -cranial tension. The flap was
replaced. The child had very little pain subsequently.
Second Stage^ June i^th. — A flap was cut in the dura,
when the brain at once protruded. No tumour was
found on exploring the interior of the cerebellar lobe.
The brain bulged so much that the dura could not be
stitched in place, and only the scalp flap was replaced.
June 26th. — The child stood the operation very
well, but was sick this morning, and continued so all
day. July ist. — Most of the stitches removed ; the
OF TUMOUR OF THE BRAIN 259
flap is beginning to bulge. Fluid allowed to escape
from behind ear. July ']th. — Wound is quite healed.
Eyes examined ; the optic neuritis has improved con-
siderably in both. The flap is bulging more. July
\^th. — Child gets up and walks about ; the gait is rather
stiff". Reflexes normal. August yd. — The flap is bulging
more than ever. The pupils are dilated ; no nystagmus.
August 14//2 — Second Operation. — ^The bone was re-
moved from the left cerebellar fossa. A tumour was
seen through the dura. A. flap of dura was turned
down. A large tubercular tumour, which extended
down to the foramen magnum and occupied nearly
the whole cerebellar fossa, was removed. It was
firmly adherent to the under surface of the tentorium
behind. The flap was then replaced, a drain of gauze
being left in the middle line. The tumour in this case
was larger than in Case 3. In the evening the tem-
perature rose to ioi\6 ; a great deal of cerebro-spinal
fluid escaped. The child vomited several times.
July 15//Z. — Vomiting continued, profuse discharge
of cerebro-spinal fluid. July 16th. — Vomiting con-
tinues ; the child very restless, tossing about. The
pulse is very poor, the child apparently dying. 2
P.M. — Three-quarters of a pint of saline, with 4
minims of liq. morph. (i in 40), infused into a
vein in the arm. Child went to sleep immediately ;
colour returned ; pulse improved, and vomiting ceased.
5.45 P.M. — Infused with ^ pint with min. 2 liq.
morph. July i Jth. — Had a quiet night ; can now
take fluids by the mouth. Temperature above 105°.
At 9 A.M. was infused with -^ pint with min. 3 liq.
morph. July iStk. — Sick twice in night and once at
mid-day ; infused |- pint with liq. morph, min. 2.
Takes plenty of milk by mouth. Wound dressed
26o SOME POINTS IN THE SURGERY
every day ; looks well. July lyd. — The flap on left
side has begun to bulge. July l^th. — Headache ;
sick once to-day. July it^th. — Headache present.
The wounds bulge, but are completely healed. A
probe was put through the wound, and a considerable
amount of cerebro-spinal fluid escaped under pressure.
July ^i^th. — When the wound bulges and no leak
occurs there is headache, and vice versa. The tem-
perature, which has always been from ioo° to 102°
since the operation, has now come down to normal.
The child is well enough to sit up and knit. September
2nd. — A leak had again to be allowed on account of
bulging and headache ; this relieves both conditions
at once. September ^th. — The scar is firmly healed
everywhere, except the small hole behind the ear where
the leak is allowed. Vomited several times to-day.
September c^th. — Vomiting continues ; child looks ill ;
food by mouth stopped. September 6th. — Vomiting
continues ; pulse very feeble ; condition very restless.
Was infused twice with i pint of saline with 3 mins.
of liq. morph. After the first infusion the vomiting
ceased, and the temperature, which was 103°, fell to
99", and she was able to take fluid by the mouth to
assuage thirst. September jth. — Infused once after
being sick. No leak of cerebro-spinal fluid. September
2>th. — Vomited eight times to-day. September ()th. —
Vomited four times. The optic neuritis is not better.
No leakage. September loth. — The bulging of the
flaps was so great that some cerebro-spinal fluid was
allowed to escape ; vomited only once. September
nth. — Considerable leakage has occurred, and the
bulging has subsided ; no more vomiting, September
13//2. — Child has been better and brighter in every
way. No more vomiting ; takes her food by the
OF TUMOUR OF THE BRAIN 261
mouth ; the leak is stopping and the bulge recurring.
September" i^th. — Seemed very well in the morning,
but about 11.30 A.M. she had a fit, which affected at
first her face only, and very shortly afterwards her
whole body was convulsed for a few moments. The
face, floor of the mouth, and the tongue remained
twitching till about i p.m., when some cerebro-spinal
fluid was let out and the twitching ceased ; but the
Fig. 120. — Haemorrhage tearing up left cerebral hemisphere.
(Garrod and Ballance.)
Large tubercular tumour removed three months before from left cerebellar fossa.
The patient was a girl 7 years and 10 months old.
child remained unconscious, with the arms rigid and
the left pupil widely dilated ; the pulse was 70. This
condition was unchanged till 5.30, when the respiration
suddenly stopped. As the heart continued to beat,
artificial respiration was kept up for sixty-five minutes.
Then as the whole course of the symptoms was thought,
possibly, to be due to recurrence of the tumour, it was
decided to explore the cerebellum. The child was
taken to the theatre, and artificial respiration being
continued, the left side of the cerebellum was exposed.
No tumour was found. The brain bulged strongly,
and was discoloured with blood ; a good deal of clot
262 SOME POINTS IN THE SURGERY
was removed from the surface. The breathing, which
was resumed after the flap had been thrown down and
the pressure relieved, now stopped again. As the
heart could not be heard after the injection of ether, the
child was thought to be dead, and beyond sewing up
the wound nothing was done. The parents were
interviewed, and about a quarter of an hour later they
left the child. The apparent death took place at 7.10.
At 7.45 the Sister of the ward thought she detected
a slight movement. On watching carefully shallow
respirations were observed at the rate of two per minute.
These gradually increased till the rate was five per
minute. On listening carefully to the heart it was
found to be faintly beating 54-56 per minute. Hot
cloths were applied and stimulants injected. There
was no other sign of life ; the sphincters were relaxed,
and no effort at swallowing made. The eyes were
examined, but the corneas were opaque, and prevented
the retina being seen. The heart and respirations
stopped gradually at 8,30.
Post-Mortem Examination. — -No tumour was found.
The left side of the brain was discoloured with blood,
the veins being engorged with blood over the vortex.
The longitudinal sinus was solid with ante-mortem clot.
On section the left half of the cerebrum was found to
be ploughed up with a large hasmorrhage, which had
spread upwards apparently from the lower and back
part of the hemisphere. There was no blood in the
ventricle, and the cause of the haemorrhage was not found.
Remarks. — This case is a good example of one in
which a regional diagnosis was impossible. It is well
known that scurvy in children is not an infrequent
cause of haemorrhage, and I am inclined to think that
the long illness of this child had induced a scorbutic
condition of the blood.
OF TUMOUR OF THE BRAIN 263
For the notes of Cases 2, 3, and 4, and for unre-
mitting and skilful care of these three children, I am
indebted to Dr. FitzWilJiams, the extremely able House
Surgeon of the Hospital for Sick Children.
Fig. 121. — Fibro-plastic tumour of Lebert, 1851.
The specimen was shown by M. Broca at the Anatomical Society of Paris. The
tumour was growing from the pia mater, the vessels of this membrane ramifying on
both surfaces. The cerebellum and pons were hollowed out to receive it, but the
substance of the brain was not invaded by the growth. The external surface was of
a reddish grey colour. On section the surface was of an ashy grey colour, with
vascular streaks and blaclc patches of haemorrhage. The consistence of the tumour
was firmer than that of the brain, and, microscopically, cells and fibro-plastic tissue
were seen. There are no clinical details, the tumour having been found accidentally
in a woman who died of peritonitis.
Fig. 122. — Fibro-plastic tumour of cerebellar meninges. (Cruveilhier, 1830.)
The medulla was pressed on by the tumour, so that a shallow depression was
formed in which the tumour lay. The medulla was in no way invaded by the
growth. No clinical history is given.
264 SOME POINTS IN THE SURGERY
Fic. 123. — Fibro-sarcoma of cerebellar meninges. (R. C. S. Museum, 3787.)
The specimen came from the museum of G. Langstaft' to the College of Surgeons
in 1835.
The tumour is spheroitlal, and presses on the nerves emerging from the right side
of the pons and medulla. It is encapsuled, hard in consistence, and, microscopically,
is a fibro-sarcoma. (Shattock.)
Fig. 124. — Tuberculous tumour of the cerebello-pontine angle. (Auvert.)
Male, aged 30. Severe blow on head three years before admission to hospital.
When seen, apathetic, emaciated, nearly blind, all four limbs paralysed, partial loss
of sensation on right side of body, and severe left hemicrania. Death three weeks
later from convulsions followed by coma.
The paralysis of the homolateral limbs is now explainable, and that of the contra-
lateral limbs was due to pressure on the pyramidal tract above the decussation.
OF TUMOUR OF THE BRAIN 265
Fic. 125. — Upper surface of cerebellum, showing a solitary tubercle in each
hemisphere. (Cruveilhier.)
From a child 9 years of age.
The failure of operation for solitary tubercle may be due to the presence of other
tubercular tumours unsuspected during life. This is especially true of the disease in
childhood.
Fig. 126. — Endothelioma of cerebellum. (R. C. S. Museum, 3863, A.)
Occupying the posterior surface of the left lobe is a rounded firm tumour. The
surface is covered by the membranes, and it lies in a deep indentation of the cere-
bellum.
From a patient who suffered from osteitis deformans.
266 SOME POINTS IN THE SURGERY
Fig. 127. — Solitary tubercle of cerebellum. (R. C. S. Museum, 3786.)
The tumour is firm, oval in shape, and measures 2 in. and i^ in. in its chief
diameters. It is deeply imbedded in the upper part of the cerebellum. It lies
directly beneath the pia, and is loosely connected with it and the other adjacent
parts.
Fig. 128. — Simple cyst of cerebellum. (R. C. S. Museum, 3778 C.)
The ri^ht lobe of the cerebellum is occupied by an oval cyst measuring 2 inches
in its longest diameter. The wall is formed by a delicate smooth membrane.
From a man, aged 36, who presented symptoms of cerebral disease a few weeks
before death. Presented by Dr. Gulliver, 1891.
OF TUMOUR OF THE BRAIN 267
Fig. 129. — Spindle-celled sarcoma of the auditory nerve, the size of a walnut,
growing into the internal auditory meatus. (Politzer.)
0, Tympanic cavity with malleus and incus ; -v, vestibule ; c, cochlea ; T, sarcoma
of auditory nerve ; «, the new growth extending into the internal meatus.
History of Case. — Patient a woman. Total deafness for ten years. Three months
before death double optic neuritis, soon followed by left -sided facial palsy and
dementia.
Autopsy. — The facial and auditory nerves were involved in the tumour. No
changes had taken place in the tympanum, vestibule, or cochlea.
The specimen was obtained by Dr. von Millingen, of Constantinople, and sent
by him to Prof. Politzer.
268 SOME POINTS IN THE SURGERY
Fig. 130. — Tumour of left auditory nerve. (Sharkey.)
V, fifth nerve 5 VI, sixth nerve ; VIIa, facial nerve ; VIIb, auditory nerve ;
VIII, vagus nerve.
R. G., aged 41, vifas admitted to St. Thomas's Hospital in 1887.
Present Illness. — Gradual onset for many months. Pain in the head, attacks of
vertigo, left ear tinnitus and deafness, some loss of sight, and loss of flesh and
strength. Has never vomited.
Stale on Admission. — Total deafness left ear. Double optic neuritis. No paralytic
symptoms. Headache, giddiness, tinnitus, and attacks of unconsciousness.
Six months later the vision was more impaired, hallucinations of vision and fits
occurred, and there was left facial paralysis.
Nine months after he was first seen patient died.
Autopsy. — The tumour occupied the cerebello-pontine fossa. It lay in a deep
cup-shaped cavity in the left lobe of the cerebellum, and had flattened the left side
of the pons and medulla. A portion of the tumour had expanded the internal
auditory meatus, and had evidently arisen as a growth from the auditory nerve.
Microscopically the tumour was a mass of spindle cells.
Remarks. — Some years ago I observed a somewhat similar case in a woman. At
the present day such a tumour would be removed.
OF TUMOUR OF THE BRAIN 269
'J>
Fig. 131. — Endothelioma of cerebellar meninges. (R. C. S. Museum, 3779, C.)
F. F., aged 26, admitted into St. Thomas's Hospital under care of Dr. Sharkey,
June 1902. Three months previously the patieat began to suffer from frontal
headache and vertigo ; the sight was beginning to fail, and there were occasional
attacks of vomiting. The headache increased, and was often severe at the back of
the head. Two months ago double vision was noticed, with ataxy and difficulty in
walking, and deafness of the right ear. On admission the gait was cerebellar.
There was no paralysis of limbs and no anaesthesia j double optic neuritis, lateral
nystagmus, and slight skew deviation of eyeballs ; deafness of the right ear ;
occasional vomiting. Headache in right occipital region, increased by mental
exertion ; inco-ordination of right hand j right-sided hemiataxia ■ tendency to fall to
the right and rotate to the left ; head depressed towards the right shoulder.
Operation in Two Stages. — August I2, 1902. — I removed the bone over the right
lateral lobe of the cerebellum. August 16. — The dura was opened and the tumour
removed ; the latter was firmly attached to the dura mater on the posterior surface
of the petrous bone.
On removing the growth two spurts of blood occurred ; the haemorrhage was
quickly controlled by pressure. Death took place twenty-four hours later, although
bleeding did not recur. At the autopsy the tumour was found to have been
adherent to the dura mater over the lateral and superior petrosal sinuses j this
portion of the dura was softened, and the haemorrhage had taken place from the
lateral and superior petrosal sinuses.
270 SOME POINTS IN THE SURGERY
Fig. 132. — Glioma filling fourth ventricle. (Norfolk and Norwich Hospital
Museum, No. 144.)
E. L., aged 11. Female.
Admitted into hospital, August 11, 1900, and died the same day.
Pain in head and back of neck for last eight months j much worse last six
weeks, vomiting, staggering gait, and failing eyesight ; unable to walk alone for last
three weeks. Two generalised fits five days previously, the first lasting quarter of
an hour, the second half an hour.
Came into hospital in maniacal condition, shouting and throwing limbs about ;
resented being interfered with in any way. If quiet at all, assumed position of
general flexion ; pupils widely dilated, hardly reacted to light at all.
Died suddenly in the afternoon in a condition of asphyxia.
P.M. — Tumour in cerebellum over fourth ventricle. No other tumour in brain.
Great excess of cerebro-spinal fluid.
Other organs healthy.
OF TUMOUR OF THE BRAIN 271
Fig. 133 . — Fibroma growing from the left acoustic nerve, compressing the left lateral lobe
of the cerebellum and the lower surface of the left temporal lobe. (Weisenburg.)
The tumour was 3 cm. wide and 2^ cm. in the sagittal direction.
The record of this case is given by Dr. Mills in full. It shows how clinically
such a growth can be overlooked. At the necropsy the tumour was found together
with internal hydrocephalus. For the relief of the syndrome symptoms an operation
was performed by Dr. Frazier, the prefrontal region being selected.
" Fibromata are rare, but are relatively more frequent in the cerebellum than in
the cerebrum. The majority of these tumours are on the left side. They may
undergo cystic, fatty, or myxomatous degeneration. Most writers persist in calling
these tumours neurofibromata. The best example of a true neurofibroma is the
amputation neuroma, therefore fibroma would be a better term for these growths.
Because of the slow growth and the nature of the tumour, clinical symptoms
may not appear at all. There may be no symptoms of such a growth, the tumour,
unsuspected before, being found at the necropsy."
272 SOME POINTS IN THE SURGERY
Fig. 134. — A tumour the size of a bantam's egg, of a firm fibrous consistence,
in the left cerebello-pontine space. (Fraenkel and Hunt.)
Married woman, aged 51 years. Mental state defective. For i-g years had
weakness of left leg, arm, and face. Hearing impaired, left side. Illness said to
have begun six years before. Initial symptoms, headache and vomiting. Vision
defective from neuritis, worse on left side. Paralysis of left external rectus. Ataxic
walk with tendency to fall to left side.
Fraenkel and Hunt report five cases, two of the left acoustic nerve, one of the
right, one case of bilateral tiimour of the acoustic, and one of tumour of the right
trigeminus.
" In this group of tumours there is an early appearance of symptoms referable to
involvement of a single cranial nerve. The 8th, 5th, and 7th nerves may be
involved ; hence occur tinnitus, vertigo, deafness, facial neuralgia, and facial palsy."
OF TUMOUR OF THE BRAIN 273
Fig. 135. — Neurofibroma of the right acoustic nerve.
(Fraenkel, Hunt, Woolsey, and Elsberg.)
Male, aged 48. Five years before being seen, diminution of hearing right side.
Three years ago, cerebellar gait. Two years ago, impairment of vision.
On examination : — Ataxic gait ; falls to left side ; mental apathy j double optic
neuritis 5 right facial paralysis last four months ; right extremities ataxic, left
spastic ; headache not generally severe ; conjunctival and corneal reflexes absent ;
tenderness right occipital region. Patient died forty-eight hours after first stage
operation.
The authors describe another case in a man aged 42, also fatal after operation.
In this patient, as in the one described, the 5th, 7th, and 8th cranial nerves on the
side of the tumour were involved.
At the end of the paper a resume of six other cases previously published is given.
274 SOME POINTS IN THE SURGERY
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Fig. 136. — Encapsulated sarcoma of the cerebellar meninges compressing upper
surface of vermis. (Hendrie Lloyd and Perceval Gerson.)
F. E., male, aged 21.
Discharged in 1894 from nautical school ship for stupidity and insubordination.
Subsequently became irritable, melancholy, and suffered frequent headache.
No history of trauma.
Present Illness. — In August 1897 intense headache, dull mentally. Failure of
sight and hearing.
On and after Admission to Hospital, February 1898. — Semi-stuporous condition.
Limbs flexed. Head held by hands. Complains of pain in head. Can scarcely
stand, and if assisted to do so has tendency to pitch forward. Total deafness.
Double optic neuritis. Patellar jerks change in intensity — normal, minus, or plus.
Several attacks of vomiting. Study of various forms of sensation impracticable.
Patient became gradually weaker, respirations assumed Cheyne-Stokes type, and
patient died April 3, 1898.
Autopsy. — A large encapsulated nodular tumour was found lying upon the
vermiform process beneath the tentorium. It had grown from the meninges. It
was not adherent to the brain, but had compressed the vermis and quadrigeminal
bodies. The tumour vv^as 6 cm. vi^ide and 6.5 cm. long. The tumour was vascular
and wfas a sarcoma. The aqueduct of Sylvius was pervious. The ventricles were
much distended.
OF TUMOUR OF THE BRAIN
275
Fig. 137. — Fibro-sarcoma of left cerebellar hemisphere. (Chance and Spiller.)
Male, aged 26. Severe occipital headache, Easter 1904. In July vomiting
occurred. In November paralysis of left external rectus, dimness of vision, and
photophobia. In December slight left facial palsy and double optic neuritis.
Patient gradually deteriorated, and developed a tendency to fall towards the left side.
He died suddenly on April 7, 1905.
Remark^.- — -The tumour was situated upon the outer portion of the left lobe of
the cerebellum, to which it was only loosely attached. It was very favourably
situated from the point of view of operation. It measured 4 x 5.5 x 5 cm., was
hard in texture, and had deeply indented the cerebellar hemisphere. The third and
lateral ventricles were somewhat dilated.
276 SOME POINTS IN THE SURGERY
Fibrosarcoma of Cerebellar Meninges.
Figs. 138 to 144.
To prove that operation for cerebellar tumour
in the adult may be completely successful, I may
mention that in 1894 I removed an encapsuled
iibro-sarcoma from the right cerebellar fossa of
a woman aged forty-nine years, and that she is
alive and well now. The following is an account
of the case : —
Female, aged forty-nine. Seen with Mr. Lunn and
Dr. Beevor.
Family History. — One brother and one sister died of
phthisis. Present Illness. — Twelve months ago began
to suffer from vertigo and pains in head, chiefly in
frontal region, and mental dulness. During last six
months eyesight has been failing and the right ear
became deaf During the last three months pain in
the back of the head has become more marked, and she
has had several attacks of severe vertigo and right ear
tinnitus ; she has never lost consciousness. Has lost
flesh and strength lately. No history of injury.
Present Symptoms {^November 14, 1894). — Headache,
vomiting, double optic neuritis : right disc more swollen.
Right grasp less than left. Right knee-jerk more brisk
than left. Is giddy when walking, and tends to fall
towards the left. Lateral and vertical nystagmus :
former more marked on looking to left. Scars of old
suppurative otitis on right drum. No tenderness on
percussion of cranium anywhere. Watch heard at half
inch on right side ; left ear hearing normal. No
anassthesia anywhere or loss of muscular sense. No
inco-ordination of upper limbs.
OF TUMOUR OF THE BRAIN 277
Fig. 138. — Photograph taken during operation.
Fig. 139. — Photograph taken at completion of operation.
278 SOME POINTS IN THE SURGERY
„l,rnjJ Ouiltorx
Oigmoitl Siitya
'cvt eig«a of SciJp
\ . '(cyX edg«a ot Scijp
-J V. if Cut eclg^s
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of Dur«L MiLep
Fig. 140. — The diagram represents a nearly horizontal section passing through the
petrous. It was drawn the day after the removal of the tumour. It shows the
extent of the opening in the bone and dura, and the position of the tumour
before its successful removal.
Fig. 141. — Photograph of tumour immediately after removal.
OF TUMOUR OF THE BRAIN 279
Fig. 142. — Drawing of right occipital region of skull, showing the outline of the scalp flap, the
portion of bone removed, the course of the sigmoid sinus, and the site of the exostosis.
28o SOME POINTS IN THE SURGERY
Operation^ November 19, 1894. — Scalp flap thrown
down in right occipital region and bone removed.
Towards the external occipital protuberance an exostosis
was discovered and removed. The exostosis presented
towards the dura as well as externally. The inward
projection had occluded the lateral sinus. When,
therefore, the exostosis was removed the sinus filled up,
causing a considerable alteration in the venous circula-
FiG. 143.— Inner aspect of bony groove for lateral sinus in the region of the
exostosis. Note that the exostosis projected inwards, and thus obliterated the
groove.
tion. The result was the patient collapsed, and
respiration ceased. Patient was revived with much
difficulty.
Operation^ November 26, 1894. — Flap thrown down,
and then dural flap thrown down. Solid tumour found
attached to dura over inner part of posterior surface of
petrous. Somewhat firmly fixed, and the finger had to
be insinuated between pons and tumour to get it
away.
Patient, after a somewhat protracted convalescence.
OF TUMOUR OF THE BRAIN 281
recovered. The fifth and seventh nerves were injured
at the operation, and the right eye ulcerated and had
to be removed. The optic neuritis in the left eye
Fig. 144. — Patient twelve years after operation for cerebellar tumour.
(Mr. Lunn's case.)
The scalp flap is concave. The ala nasi has been destroyed by trophic ulceration,
the result of injury to the fifth nerve.
cleared up with recovery of good eyesight. Some
trophic ulceration occurred at the angle of the mouth
and at the right ala nasi ; this ultimately healed.
282 SOME POINTS IN THE SURGERY
September 1906. — Patient is alive and well, but has
right facial palsy and anassthesia corresponding to the
right fifth nerve.
Figs. 145 to 148, illustrating a case of Compound Com-
minuted Fracture of the Skull and Laceration of the
Brain which was under my care twenty years ago.
The case is introduced so that a comparison may be made between Fig. 14:;
and Figs. 81, 82, 83, 118, 119, 144, 171, and 172. After the comminuted
fragments of a fracture of the skull are removed, and the patient recovers,
the scalp falls in, forming a concave depression. The same is true after removal
of a brain tumour so soon as the conditions within the cranium become normal.
Recurrence or regrowth of tumour, or conditions which make for a continuance
of abnormal intra-cranial tension, cause the scalp depression to disappear.
The scalp over the cranial defect will then be on the same level as the rest of
the scalp, or it will bulge. Concavity of the scalp flap will thus point to complete
recovery, and convexity to a persistence of abnormal intra-cranial conditions.
Figs. 81, 82, 83, and 172 show bulging of the flap. In the cases represented in
Figs. 81, 82, and 83 no tumour was removed: the cause which produced the
symptoms of tumour persists though the urgent symptoms are relieved. In Fig. 122
the scalp previously concave after removal of the tumour again became convex as
the growth recurred.
I'he patient, a man aged 26, was brought to the West London Hospital in an
unconscious state. He had been kicked a short time previously in the stable on the
right side of the head by a horse of which he had charge. A very severe com-
minuted " saucer " fracture had occurred, sharp haemorrhage was taking place from
the middle meningeal artery, and there was considerable laceration of the anterior
region of the frontal lobe.
The surgical treatment need not be described. The man made an excellent
recovery, and eight months after the injury was driving a pair of horses about
London all day.
OF TUMOUR OF THE BRAIN 283
Fig. 145. — Portrait of patient eight months after injury (August 1886). The hair,
which had grown freely over the depressed scalp, was cut off for the purposes
of this sketch. The slight appearance of squint is incorrect.
284 SOME POINTS IN THE SURGERY
Fig. 146. — Diagram two-thirds natural size, showing the extent of the depression
in the temporal region. The normal sutures, the lines of fracture, and the position
of the middle meningeal artery are marked. The artery below the point where it is
in<licated by a dotted line entered a canal in the bone. The small diagram in the
upper right-hand corner is to make clear the points of breakage and ligature of the two
main branches of this vessel. x indicates about the point where the calkin or heel
of the horseshoe drove a portion of skull into the brain. The semicircular line of
fracture behind this point was evidently caused by the semicircular edge of the
horseshoe. The bone along this line was so cleanly fractured that it looked as if it
had been cut with a knife.
Fig. 147. — Diagram (natural size, and taken from the pieces of bone which were
removed after they had been fitted together). The breaking away of the inner table
to a greater extent than the outer, and the close and even fitting of the fragments at
the lines of fracture is represented. The depression partly caused the locking of the
fragments, as it was not abrupt, and any attempt at elevation only jammed them
more tightly together, hence the resort to the trephine. The foramen is for the
middle meningeal artery.
OF TUMOUR OF THE BRAIN 285
Fig. 148. — Diagram (two-thirds natural size) to show the extent of brain, which
can now be felt pulsating underneath the scalp. Part of the Sylvian fissure, and
convolutions and sulci of the frontal, parietal, and teniporo-sphenoidal lobes are
exposed. The figures against the straight dotted lines indicate in inches the size of
the opening. The curved dotted line separates the bone depressed by. the horse-kick
from that removed with the trephine. x shows about the spot where the calkin
or heel of the horseshoe drove a portion of skull into the brain ; * indicates the
place where a counter-opening was made in the dura mater and a catgut drain
inserted.
286 SOME POINTS IN THE SURGERY
Fig. 149.
Fig. 150.
Fig. 149. — Operation for simultaneous exposure of both cerebellar hemispheres,
necessitating ligation of the occipital sinus. (Charles Frazier.)
I. Occipital sinus which has been ligated and reflected with the dura. 2. Mastoid
process. 3. A tributary of the lateral sinus. 4. Lateral sinus. 5. Occipital
protuberance. 6. Occipital sinus.
Fig. 150. — Structures in relation to the anterior aspect of the cerebellar hemisphere
and the posterior surface of the petrous. Note the position of the 5th, 7th,
and 8th cranial nerves. 2. 9th, loth, and i ith cranial nerves. 3. Auditory
nerve drawn to one side. 4. The facial nerve is seen on its inner side.
5. Root of trigeminus as it enters the groove on the apex of the petrous.
Frazier urges early operation. He writes : As the exploratory operation is
recognised as the surest, safest, and most reliable diagnostic measure in tumours of
the stomach, it should be considered of equal value and importance in tumours of the
brain. It is unnecessary to preserve the overlying bone, therefore the osteoplastic
flap which has done so much to revolutionise the surgery of tumours of the cerebrum
is not to be employed in tumours of the cerebellum. Puncture of the ventricles and
lumbar puncture is attended by danger owing to the sudden disturbance of pressure,
as illustrated by many fatalities. Frazier recommends the removal of one-third or
one-half of the cerebellar hemisphere in order to explore a tumour before removal,
and thus avoid traumatism by the finger and undue pressure or traction on the pons
or medulla. He says the percentage of tumours found is yearly growing larger, the
percentage of partial or complete recoveries is larger, and the mortality has fallen
from 70 to 38 per cent.
OF TUMOUR OF THE BRAIN 287
Tumours of the Cerebrum.
Time will allow only a few remarks on the
localising symptoms of tumours of the cerebrum.
In man the left cerebral hemisphere controls
the highly specialised movements of the right
hand, is the seat of the sensori-motor nervous
mechanism of speech and writing, and it appears
also that the left prefrontal region is more con-
cerned with the higher psychic functions than
the right. The leading half of the cerebrum is
therefore the lett, or, as Professor Cunningham
puts it, man is left-brained and right-handed.
He writes : " It is easy to prove that the charac-
teristic right-handedness is one of vast antiquity.
Of this there is the clearest evidence, not only in
historical records and pictorial representations,
but also in ancient mythology and in the
structure of almost all languages. It appears
probable that right-handedness assumed form as
a characteristic at a very early period of man's
evolution, and most likelv before he became
endowed with the power of articulate speech.
The ape is ambidextrous. There is a much
higher percentage than in the normal individual
of microcephalic idiots who are ambidextrous.
288 SOME POINTS IN THE SURGERY
and consequently a great reduction in the per-
centage of those who are right-handed. No
sooner did man assume an upright gait than the
work of the right hand grew in importance, the
Fig. 151. — The reindeer of the cave of Thayngen, near SchaflTiausen.
(From Early Man in Britain^ by Prof. Boyd Dawkins.)
" Referring to the fact that in these sketches the animals depicted sometimes
look to the left and sometimes to the right, Sir Daniel Wilson remarks : ' This is a
nearly unerring test of right or left handedness. The skilled artist can, no doubt,
execute a right or left profile at his will. But an unpremeditated profile drawing by
a right-handed draughtsman will be represented looking to the left.' In the majority
of palaeolithic drawings within my reach the animals depicted look to the left,
which in some small degree suggests the idea of right-handedness on the part of the
artist. With regard to those in which the profile looks to the right, absolutely no
proof can be obtained either in one way or the other, and it is absurd to put them
down to the work of left-handed artists. The impression that one receives from the
engraving of the grazing reindeer is that it was undoubtedly depicted from life, and
that the animal happened to be facing to the right at the time the artist was engaged
in his work." ((Quoted from Cunningham.)
functional superiority of the left hemisphere
became pre-eminent, since all the movements
which require the higher guidance of the brain
OF TUMOUR OF THE BRAIN 289
Fig. I i2.-
-Perforated antler discovered in the cave of La Madelaine.
(M. Gabriel de Mortillet.)
A human form is seen between two horses' heads. From the attitude of the
figure and the position of the right upper limb, which holds a baton or stick, right-
handedness is strongly suggested.
"It is most unfortunate that so few of the artistic efforts of the palaeolithic cave-
dwellers have been directed to the delineation of man. By such representations
alone would it be possible to judge the point at issue." (Cunningham.)
a
Fig.
153. — Right cerebral hemisphere from a human foetus in the latter
half of the 6th month of development. (Cunningham.)
a, Elevation which corresponds to the motor area of the arm j i>, corresponding
elevation behind the central fissure.
" These cortical elevations are undoubtedly connected with the development of
function in localised areas, and represent the arm centre of the cortex. Possibly the
bulging behind the central fissure is the receptive centre to which sensory impressions
travelling from the upper limb are conveyed." Cunningham was unable to discover
in the developing brain any material difference between the arm centres of the left
and right hemispheres.
U
290 SOME POINTS IN THE SURGERY
are performed by the right hand. Further,
the active speech centre is situated in the left
cerebral hemisphere, and the greater part, if not
the whole, of the motor incitations which lead
to articulate speech go out from the speech
centre which resides in the left cerebral hemi-
sphere. There are probably no series of motor
acts which require a greater refinement of
adjustment than those that result in articulate
speech. It is indeed remarkable that it should
have fallen to the lot of one cerebral hemisphere
to preside over the movements accompanying
speech in the same way as it presides over the
movements of the skilful right hand. If the
ape is truly ambidextrous, it is reasonable to
conclude that in the evolution of man right-
handedness did not assert itself until the upper
limb had been set absolutely free from the office
of locomotion, and had assumed the higher
duties which are now assigned to it."
Tumours involving certain regions of the left
cerebral hemisphere are liable to cause derange-
ments in the expression or in the recognition of
the visual or auditory symbols by which ideas
are communicated (the facultas signatrix), and
are therefore more easily recognised clinically
than tumours of corresponding parts of the right
hemisphere ; for example, the right temporo-
OF TUMOUR OF THE BRAIN 291
sphenoidal lobe is often described as a " silent "
region of the brain.
A brain tumour may begin in the meninges
and invade or displace the cortex secondarily, or
it may begin in the subcortical tissue and then
grow towards the cortex or towards the deeper
parts, such as the internal capsule. The history
of the case and the march of the symptoms may
decide this point. A meningeal tumour, or one
invading the cortex, may be the cause of local
tenderness or pain on pressure or percussion.
Abducens palsy is not a localising symptom.
Tumours growing in the deeper parts of the
brain, such as the optic thalamus, the corpus
striatum, or the pituitary body, are at present
spoken of as " inoperable." This is incorrect,
for much may now be done for these cases by
decompressive operations, and it is by no means
improbable that in the near future they will be
successfully removed. A fit is, as we all know,
an occurrence common to irritations arising in all
parts of the cerebral cortex. Its localising value
depends on the recognition of the site of the
initial local spasm, or the clear description by
the patient of a psychic or sensory aura preceding
the fit. The persistence of a local paralysis after
the conclusion of a fit is evidence of a gross
lesion. A sensory aura — olfactory, auditory, or
292 SOME POINTS IN THE SURGERY
Fig. 154. — Sarcomatous solid tumour of (?) optic thalamus.
J. M., aged 40, admitted to the National Hospital under the care of Dr. Ferrier.
He was afterwards under the care of Dr. James Taylor, who asked me to operate.
The patient is a left-handed man with right hemiplegia. He used to bowl with
the left hand, but writes and feeds himself with the right hand.
One year ago he commenced to have difficulty in writing with the right hand.
Five months ago in India he had several " fainting attacks " and lameness of right leg.
He then came to England, and shortly afterwards was admitted to hospital.
There was right hemiplegia most complete in arm. Speech slow, difficulty in com-
pleting a sentence, sometimes used wrong words, easily confused, and emotional.
The left superior parietal region was tender to firm pressure. The right side was
incompletely hemiansesthetic and hemianalgesic j the loss of sensation did not affect
the face, and was most marked in the right hand and foot. The sphincters were
unaffected. Headache was severe, and double optic neuritis was present. Anti-
syphilitic treatment did not have any effect on patient's condition.
The patient gradually became worse ; the optic neuritis increased, the headache
was very severe, the mental dulness and difficulty in speaking increased, and
operation was decided on.
Operation. — The bone was removed over the left parietal region, and over the
posterior part of the left upper frontal region. On opening the dura, which was
under considerable tension, the convolutions were found to be flattened, but no
tumour could be felt by palpation through the cortex. An incision sufficient to
admit the finger was made through the caudal extremity of the first frontal
convolution. On introducing the finger through the cortex into the centrum ovale
for \\ inches in a direction downwards and backwards, a hard, rounded tumour
was felt, and slowly enucleated with the finger. There was no material haemorrhage
and no shock. The wound was closed in the ordinary way.
The tumour was about the size of a golf ball. It measured i| x i J X \\ inches,
and weighed just 2 oz. The removal of the tumour was effected without opening
the ventricle. As the tip of the finger reached the deepest surface of the tumour
the whole finger was enclosed within the brain. The tumour must have occupied
a subependymal position, and was at the site of or close by the optic thalamus. On
making a brain section and measuring the distance from caudal extremity of the
first frontal convolution to the optic thalamus, it was found to be 7.\ to 2| inches.
On microscopical section the central part of the tumour was found to be
degenerating.
After the operation the headache disappeared, the wound rapidly healed, but for a
few days the aphasia was almost complete. Four iveeks after operation there was no
headache, the optic neuritis had subsided, and speech was much improved ; the arm
was still paralysed, but the right hip and knee movements were strongly performed.
The hemianesthesia was much less than before operation. Mentally, patient was
bright, but was easily fatigued by conversation. The first time he sat up out of bed
he complained of frontal headache, but this was at once relieved when he got back
to bed.
OF TUMOUR OF THE BRAIN 293
visual — localises the tumour behind the motor
region. Idiopathic epilepsy, haemorrhage, de-
mentia, and melancholia must be recognised
apart from brain tumour. Among the sources
of error in localisation may be mentioned
multiple tumours and oedema spreading widely
Fig. 155. — Spreading cedema of the centrum semi-ovale, from a small nodule in the
right prefrontal cortex, secondary to a renal carcinoma. (James Collier.)
The cerebral symptoms were very urgent, and death occurred in fourteen days
after their appearance. There were no localising signs during the first seven days.
The white matter of the right hemisphere was enormously swollen, softer than
normal, and somewhat jelly-like in appearance.
from a tumour — a condition described by James
Collier. It is often difficult to determine
whether tumour is present or not when the
symptoms are not typical, and it is to be borne
in mind that large, slowly- growing tumours
may be present without any symptoms which
are unequivocal. For example, epileptic fits
294 SOME POINTS IN THE SURGERY
and headache may lead to the suspicion of
the presence of tumour years before other
symptoms arise which justify operation. It was
formerly thought that occasional fits beginning
locally, followed by loss of consciousness, though
attended by persistent local headache, would not
justify an operation unless optic neuritis was
present. The importance of opening the skull
before the tumour has attained a large size is
now recognised ; it is also known that optic
neuritis may not be manifest till shortly before
death ; and it is no longer thought necessary,
but rather disastrous, to await the completion of
the syndrome before operating. Surgical inter-
vention is, unhappily, still our only remedy for
certain classes of brain tumours, but only too
generally the same apathy prevails in adopting
this remedy as was prevalent twenty-five years
ago in operating for analogous disease in the
abdomen. It has been already pointed out that
the difficulty of making a precise diagnosis at an
early stage of the disease is prominent among
the obstacles to successful operation. Not many
years ago the nature of many abdominal diseases
was not ascertained until the abdomen had been
opened. In the early Listerian days the con-
dition found on opening the abdomen often
differed widely from that expected. This is
OF TUMOUR OF THE BRAIN 295
much less frequently the case now. The
diagnosis of intra- cranial disease is, speaking
generally, a far more complex problem than that
CONCRETE CONCEPT
Fig. 156. — Areas and centres of the lateral aspect of the human
hemicerebrum. (Mills.)
Fig. 157. — Areas and centres of the mesial aspect of the human
hemicerebrum. (Mills.)
of intra - abdominal disease ; and, moreover,
within the skull an exploratory operation cannot
be conducted in the same rapid and complete
manner and with so little serious risk as in the
296 SOME POINTS IN THE SURGERY
abdomen. The maxim that diagnosis must
precede operation is only true of those diseases,
the signs, symptoms, and course of which are
fully comprehended. When the early clinical
manifestations of a disease are ill understood,
and when danger attends delay, the surgeon is
content to act upon a provisional diagnosis.
Many lives are thus saved, and diagnosis becomes
perfected.
The signs and symptoms of tumour of the
occipital, frontal, and parietal regions will now be
briefly referred to, and some cases related which
illustrate the statements made. The functions
of the cortical regions of the cerebrum are illus-
trated by the diagrams of Mills. The convexity
of the hemisphere is the region of most interest
to the surgeon, since it is the surface which is
exposed in all procedures for the operative
removal of brain tumours. The other surfaces
and the deeper parts are not so directly accessible,
and will only be incidentally referred to in this
lecture.
OF TUMOUR OF THE BRAIN 297
Tumour of the Occipital Lobe.
In the cortex of the occipital lobe and of
the adjoining parts of the parietal and temporo-
sphenoidal lobes are situated the visual centres.
Various authors agree in stating that the retina
is represented on either side of the calcarine
fissure. The primary visual cortical centres
are on the mesial part of the occipital lobe.
Here objects are seeti^ while in the higher
visual centres they are recognised. These higher
visual centres lie in the cortex of the outer
aspect of the occipital lobe, and extend on to
that of the adjacent lobes. Possibly the centres
for colour recognition lie in the cortex of the
convolutions (temporo-occipital) of the tentorial
aspect of the occipital lobe.
Henschen of Stockholm has met with a
remarkable series of cases illustrating the cortical
localisation of the sense of vision as distinct from
the higher centres for the recognition of things
seen. When the grey matter of the calcarine
fissure, or the fibres of the optic radiation leading
thereto, are destroyed, the patient does not see
objects on the contra-lateral side of the median
line (homonymous lateral hemianopsia). When
298 SOME POINTS IN THE SURGERY
the higher centres on the external aspect of the
cortex are destroyed, the patient has, not hemi-
anopsia, but mind - blindness, word - blindness,
and other defects of appreciation of the objects
seen, — seeing, he sees but does not perceive.
These higher visual centres attain a higher
degree of evolution in the cortex of the left
hemisphere. Not only does a total lesion of
the calcarine visual centre produce complete
hemianopsia, but a partial lesion of the grey
matter of the calcarine fissure (or of the optic
radiation) produces an absolute scotoma of
constant nature. A lesion limited to the upper
lip of the calcarine fissure determines a scotoma
involving the upper part of the contra-lateral
half of the visual field, a lesion limited to the
inferior lip of the calcarine fissure determines a
scotoma involving the lower part of the contra-
lateral half of the visual field, lesions of the
bottom of the calcarine fissure determine a
scotoma involving the middle portion of the
contra-lateral half of the visual field. Henschen
gives several charts of visual fields from cases
illustrating his views. He also relates the
following remarkable case of bilateral lesion : —
In the left hemisphere the cortex of the calcarine
fissure was destroyed, the lesion only involving
the white matter quite close to the occipital
OF TUMOUR OF THE BRAIN 299
pole, so that there was no question of even a
partial involvement of the optic radiation.
Besides this, nature had made a remarkable
control experiment ; the lateral surface of the
other (right) hemisphere was to a great extent
destroyed, but this second lesion did not give
rise to hemianopsia, which was present only on
the right side of the field of vision. He also
relates a case in which there was hemianopsia
and scotoma due to the presence of a bullet
which had lodged in the calcarine fissure, and
which was successfully removed.
Touche of Brevannes considers that there is
a special centre for " topographical memory,"
which he defines as the faculty of recollecting,
not the objects themselves, but their relative
positions in space. He instances a patient who
could describe perfectly Notre Dame, the Hotel
Dieu, and the Palais de Justice, but could not
describe their relative positions to one another
and to the Seine, though he had lived for many
years in that part of Paris. His conclusions
are — i. That topographical memory may be
affected independently of its constituent elements.
2. That a lesion of the left hemisphere only
will determine its loss. 3. That the centre for
topographical memory is on the inferior surface
of the temporo-occipital lobe. 4. That complete
300 SOME POINTS IN THE SURGERY
destruction of what is ordinarily termed the
visual area (the cuneus, the lingual and fusiform
lobules) on the left side is compatible with the
persistence of the memory of contours and
colours. 5. That even a partial destruction of
the fusiform lobule (middle third) on the left
side causes loss of topographical memory. He
relates cases which appear to show that when
this particular area is uninjured the patient,
though he may have hemianopsia, is able to find
his way about ; when it is destroyed, the faculty
of orientation may be lost, though there is no
hemianopsia.
The one striking symptom of tumour of the
occipital lobe is some form of defect in visual
innervation, the most common being hemi-
anopsia, the objects on the opposite side of the
median line not being seen. Hemianopsia is
almost always present, and its localising value is
especially great when it is first in date among
the symptoms of tumour. Visual hallucinations
or spectra may precede the hemianopsia, as in
the case of angiolithic sarcoma recorded in the
early part of this lecture. In a case of tumour
of occipital lobe described many years ago by
Gowers, the hallucination took the form of a
flickering of light like a golden serpent moving
very fast in all directions.
OF TUMOUR OF THE BRAIN 301
The Wernicke hemianopic pupillary reaction
is a means of determining whether the lesion
lies between the optic chiasma and corpora
quadrigemina, or farther back in the visual
Fig. 158. — Horizontal section of the occipital lobe, showing the optic
radiation (after Raymond).
Ci, internal capsule j Pu, pulvinar ; iVc, nucleus caudatus ; Hy, hippocampus j
TI2, tapetum ; i?0, optic radiation j F/z, inferior longitudinal fasciculus ; Ca/, calcarine
fissure.
pathway. If the beam of light falling upon the
blind side of the retina causes no contraction of
the pupil, it is assumed that the lesion is in that
portion of the sensori-motor arc of the pupillary
302 SOME POINTS IN THE SURGERY
reflex included between the chiasma and the
corpora quadrigemina ; if there is reaction of the
pupil the lesion is in the optic radiation or the
visual cortex. A fit resulting from an occipital
tumour may be preceded by a visual aura. As
the tumour extends forwards motor and sensory
phenomena are likely to arise on the contra-
lateral side, and in tumour of the left occipital
lobe language defects from involvement of the
angular gyrus and the caudal extremity of the
superior temporo- sphenoidal convolution. In
some cases cerebellar symptoms are observed,
such as staggering gait, Romberg's sign, etc.
The visual signs prove that the tumour is not in
the cerebellum. The cerebellar signs indicate
increased pressure in the cerebellar fossa. The
tumour does not exercise direct pressure through
the tentorium, which is much too strong a
membrane to be displaced, but blocks the
aqueduct of Sylvius or otherwise interferes
with the secretion or flow of cerebro- spinal
fluid.
OF TUMOUR OF THE BRAIN 303
Illustrative Cases.
I, A lady aged forty, a patient of Dr. Wilfrid
Fig. 159. — Glioma of occipital lobe. (Dr. Risien Russell's case.)
The section is at a low level, where the tumour is solid. It shows the involve-
ment of the optic radiations. At a higher level the tumour occupied the outer
aspect of the occipital lobe (except the tip) and was cystic.
Dawson, was confined in August. Nine days after-
wards she had a fit, but seemed to recover com-
304 SOME POINTS IN THE SURGERY
pletely. The following Easter she complained of
headache, which gradually grew more severe. Three
weeks before I saw her Dr. Risien Russell examined her
and could find no evidence of gross intra-cranial disease,
but two days previously he discovered early optic neuritis,
most marked in the right eye, and right abducens palsy.
When seen by me (in July) the headache was very
severe, vomiting had occurred off and on for six weeks,
and besides the signs mentioned above there were
staggering gait, Romberg's sign, left Babinski reflex,
complete left hemianopsia, and Wernicke's pupillary
reaction. The conditions were confirmed next day by
Dr. Russell and Mr. Gunn.
Operation. — First stage. Bone removed over right
occipital region. Great intradural pressure relieved by
withdrawing two ounces of cerebro- spinal fluid by
lumbar puncture. Twenty hours later patient died in
a fit before the dura was opened. It had been arranged
to do the second stage of the operation forty-eight hours
after the completion of the first stage.
Autopsy. — Convolutions much flattened. Large
cystic glioma of right occipital lobe. This tumour
appeared on the outer surface of the lobe, and there
was a line of demarcation between it and healthy cortex.
It could apparently have been enucleated.
Remarks. — The case illustrates the danger of sudden
death in cases of brain tumour, especially in relation to
operation in two stages. In this case the removal of
the bone over the occipital lobe was not accompanied
by any appreciable loss of blood, fall in blood pressure,
or shock. A two - stage operation is advisable when
there is loss of blood and shock, but it is not advisable
(and this case is an instance in point) when the patient
is in good condition at the conclusion of the first stage
OF TUMOUR OF THE BRAIN 305
of the operative procedure. The fact that the tumour
was cystic explains the rapid increase in pressure, the
rapid onset of symptoms, and the sudden death by
arrest of respiration.
11. A case of brain tumour in which hemianopsia
was the dominant symptom is related by Souques. A
soldier, aged twenty-three years, was taken ill one day in
April 1890 with buzzing in the ears, vertigo, mental
confusion, and aphasia ; the attack proved transitory, and
he returned to duty the next day. During the next
twelve months he had attacks at intervals, with transitory
aphasia, and became unable to read or write, so that he
was compelled to ask a comrade to read his letters to
him and to write those he wished to send. He had no
difficulty in understanding what was said to him, and
his difficulty in speaking was only transitory. In April
1891 he was admitted to hospital under Souques, the
diagnosis of the military medical authorities not having
proceeded beyond epilepsy and hysteria. He then had
optic neuritis, right hemianopsia, and agraphia ; the
agraphia was not quite complete, for he could write his
own name, and he could write figures. He could identify
any letter, whether in scrip or print, but could not
read a syllable, so that he was word blind, but not letter
blind. He could add and subtract correctly, and write
and read figures, so that the case lends support to the
view that there is a centre for numbers distinct from
that for letters and words. The patient became
gradually worse and died in August 1891. At the
autopsy a large glioma was found in the left hemisphere,
occupying the white matter of the occipito - parietal
region ; it came to the surface on the external aspect
at the angular gyrus, which it had destroyed, and on
X
3o6 SOME POINTS IN THE SURGERY
the internal aspect at the lower part of the quadrilateral
lobule. It had evidently destroyed the optic radiation.
III. Marchand relates an interesting case of blindness
Fig. i6o.
Fig. i6i.
Figs. i6o and i6i. — Symmetrical atrophy and degeneration of the occipital lobes.
(Marchand, 1903.)
Fig. 160. — Left hemisphere.
Fig. 16 1. — Right hemisphere.
from a bilateral cortical lesion. The patient, a female
then nineteen years old, was admitted to an asylum
on October i, 1880, with the diagnosis "epilepsy with
criminal tendencies." At the age of one year she had
had meningitis. Fits had commenced a year before her
OF TUMOUR OF THE BRAIN 307
admission. Fits occurred at intervals without notice-
able change for seventeen years, and then became more
frequent. With the increasing frequency of the fits
failure of sight was noticed, and speech became difficult.
Sight failed slowly and progressively, and in five years
she was, except for bare perception of light in the
central portion of both fields, totally blind. The right
side of the field of vision was first lost. Towards the
last she also lost the faculty of direction, so that she
could not find her way about the wing of the asylum of
which she had been an inmate for twenty-two years.
She died on July 14, 1902. The skull was very thick.
There was considerable excess of cerebro-spinal fluid.
The frontal, parietal, and temporal lobes were normal.
Over both the external and internal aspects of the
occipital lobes the pia mater was thickened, adherent,
and very vascular ; the surface was covered with false
membranes forming bands, which in places appeared to
penetrate into the cortex. The convolutions of the
external aspect were small, puckered, and atrophied ;
their original shape was lost, and they were penetrated
by false membranes. The appearances of the convolu-
tions on the internal aspect of both lobes were the same.
Fluctuation could be clearly felt on palpation of the
surface ; the thickness of brain substance between the
surface and the ventricular fluid was only 2 mm.
Fig. 162.— The distribution of the middle meningeal artery. (After Chipault.)
When the occipital lobe is exposed the scalp flap is turned downwards ; but the
dural flap must have its base forwards, for otherwise its blood-supply will be cut oft.
Fig. 163. — Fibro-plastic tumoLii ot cLicbral meninges. (Lebert, 1851.)
From a woman, aged 71, who was admitted to the Salpetriere on May 4, 1850,
with hemiplegia and blindness. She died suddenly and unexpectedly on Dec. 12,
1850.
Autopsy. — The tumour was intimately adherent to the dura over the right
occipital lobe. A depression, the size of a hen's egg, was present on the surface of
the occipital lobe, and in this depression the tumour lay. In structure the tumour
was fibrous. It had probably produced blindness from optic atrophy following
neuritis, and hemiplegia of the opposite side.
Lebert describes these cases as chronic, with disturbances of motion, sensation,
special sense, and intelligence.
-,08
TUMOUR OF THE BRAIN 309
Tumour of the Frontal Lobe.
The outer surface of the frontal lobe is
bounded posteriorly by the fissure of Rolando.
This is true not only from the point of
view of the anatomist, but also from that of
the physiologist, since recent experiments on
the brains of the chimpanzee and gorilla,
and actual electrical stimulation of the brain
of man, show that the motor cortex does
not extend behind the Rolandic fissure, for in
the grey matter of the precentral convolution
are represented the movements of the chief
groups of muscles on the contralateral side of
the body. The following brief remarks refer
chiefly to the left or dominant frontal lobe.
The cortex of the frontal lobe can be con-
veniently divided into a posterior part, which,
when appropriately stimulated, gives rise to
muscular movements, and an anterior part, or
anterior pole, which is " silent " when treated
in a like manner.
The posterior-frontal region is limited to the
ascending frontal convolution and a portion of
the cortex of the caudal extremities of the 2nd
and 3rd frontal convolutions, in which are
310 SOME POINTS IN THE SURGERY
represented the movements of the head and eyes.
The movements produced by stimulation of the
Abdomen
Cha&C
EueLid / ^, /
u^/^ COosure
'^■^* Opening ,
ofjarT VocsJ,
cord3. Ma^eatksn
SulctXs osntralts.
Fig. 164. — The motor area and its subdivisions on the lateral aspect of the
hemicerebrum of the chimpanzee. (Grunbaum and Sherrington.)
Sulc. CenCraL ^""^ i Vagina
Sul&ccUloso ^..,— -T*^ StLlcprecermr.marg.
SuLc.pari-eCo
Sulc.calcarin
i.l.l.dd.
Fig. 165. — The motor areas and centres on the mesial aspect of the hemicerebrum
of the chimpanzee. (Grunbaum and Sherrington.)
ascending frontal convolution are so well known
through the splendid labours of many experi-
menters and pathologists that they need not here
be further alluded to. Many tumours originate
OF TUMOUR OF THE BRAIN 311
in, or subsequently involve the motor region of
the frontal lobe, and their focal diagnosis does
not often present much difficulty. The initial
local spasm of a ifit or a local paresis is patho-
gnomonic of the site of the lesion.
The mid-frontal region of Mills contains
Charcot's motor graphic centre at the posterior
end of the second frontal convolution, and the
motor speech centre (Broca, 1870) at the
posterior end of the left third frontal convolu-
tion. Between and in advance of these centres
are those concerned with the movements of the
head and eyes. The movements of the head are
represented on a higher level than those of the
eyes. Mills says " that the symptom complex
of this region is motor agraphia, motor aphasia,
fits with movements of the head and eyes as the
salient feature of the local spasm, and psychic
symptoms of a special sort, such as transient
affection of memory."
The true anterior -frontal region is con-
cerned with the highest psychic functions, and
this is especially true of the left prefrontal lobe.
Destructive lesions in this situation give rise to
loss of the highest functions of the brain, such
as ideation, memory, control, attention, and
judgment.
312 SOME POINTS IN THE SURGERY
Illustrative Case.
Convulsions followed by Motor Agraphia.
Man, aged twenty-eight years. When eight years old
fell, striking the occiput, but no symptoms known to have
ensued. In February 1899 he had a convulsion after a
hearty meal ; a year later a second convulsion occurred,
and a third and a fourth in the course of the succeeding
six months. In June 1901 he had a series of minor
attacks ; occasionally while talking he would look
queer, appear dazed for a few seconds, and then pro-
ceed with the business in hand as if nothing had
happened. On May i, 1904, he had a convulsion
without loss of consciousness, the right side of the face
being the part affected. The attack was repeated ; on
one occasion he had twelve such attacks within two
hours. About this time he became unable to write ;
there was slight paresis of right side of face, but none
of limbs. There was no ataxia. Speech was thick, and
he paused unduly between his words ; he had no diffi-
culty in reading or in naming objects shown to him.
In attempting to write he could only make meaningless
strokes, though he held the pencil correctly, and there
was no want of precision in the movements of the hand.
His wife stated that his mental condition had under-
gone gradual change since the commencement of his
illness ; he had become irritable, and seemed less able to
understand. On May 21, 1904, the posterior part of the
left frontal region of the brain was exposed and a tumour
removed. " It lay across the foot of the second frontal
convolution, encroaching somewhat on the lower half
of the first and slightly upon the upper posterior
OF TUMOUR OF THE BRAIN 313
portion of the third frontal convolution, and on the
anterior edge of the precentral convolution. After the
operation there was paresis of the face and of the right
hand, as well as agraphia. But these soon cleared up,
and on June 12, 1904, the patient was able to write a
letter. (J. W. MacConnell.)
When there is evidence of psychic dissolution
preceding the onset of motor phenomena, the
presumption is strongly in favour of the tumour
being in the frontal lobe. Head and eye
movements, and motor speech and w^riting
defects, are also special symptoms of frontal lobe
lesions. Motor agraphia and motor aphasia are
associated with the loss of all kinds of skilled
movements of the arm and leg (Mills), such as
painting and dancing. There is no loss of
common sensation on the opposite side of the
body, but there is loss of the pov^er of localising
light touches and of muscular sense w^hen the
motor cortex is involved, as was long ago
pointed out by Horsley. This can best be
explained at the present time by the tumour not
only involving the precentral convolution, but
also extending behind the fissure of Rolando, so
as to involve corresponding areas of the sensory
cortex. There seems some doubt whether a
specific form of ataxia is determined by lesions
of the frontal lobe. Bruns attaches importance
314 SOME POINTS IN THE SURGERY
to this symptom, which in one case enabled him
to diagnose the site of the tumour ; he operated,
and the patient recovered. In another case, on
the other hand, it led Hitzig into error, for he
believed the tumour was in the cerebellum,
because of the ataxic phenomena, and opened
the skull in the occipital region, but the tumour
was in the frontal lobe. Frontal ataxia is mani-
fested when the patient stands or attempts to
walk. When stood up he sways to right and to
left, and would fall if not supported, but in
walking does not describe zigzags, and does not
stagger like a patient with a cerebellar lesion.
Some authors, for example Bruns, look upon the
condition as due to paresis of muscles of the
trunk and neck. Mills describes a case in which
the ataxia of the fore limb might be considered
as due to loss of the power of attention, the
patient being unable to convey food to the
mouth with any certainty. Grainger Stewart
has recently pointed out that a fine vibratory
tremor may occur in the extended homolateral
upper limb, and that the epigastric and ab-
dominal reflexes may be absent on the contra-
lateral side. The headache in a frontal lobe
tumour may in some part of the course of the
case be occipital in site. Some frontal tumours
fulminate with fearful headache : in one case
OF TUMOUR OF THE BRAIN 315
seen by me the man, groaning in pain, sat up
continually in bed holding his forehead with
both hands, and with the body bowed forwards
till the head touched the bedclothes. The per-
FiG. 166. — Glioma of frontal lobe.
Microscopic section by Dr. Gordon Holmes.
The upper figure shows the highly cellular nature of the growth'and the well-
formed blood-vessels. At one part of the tumour (see lower figure) some inter-
cellular tuberculas were found, but these did not stain red with the van Gieson
stain. The well-formed walls of the blood-vessels and the non-staining property of
the intercellular substance prove the tumour to be a glioma, not a sarcoma.
sistent headache of tumour is quite unlike the
transient headache sometimes associated with
idiopathic epilepsy. It may again be noted that
epilepsy may occur from irritation arising in any
part of the cortex, and not simply from irritation
3i6 SOME POINTS IN THE SURGERY
of the motor area ; that it occurs in hysteria and
idiopathic epilepsy, and in many gross lesions
other than tumour. When tumour involves the
orbital surface of the frontal lobe, symptoms
referable to pressure on or invasion of the
olfactory lobe or optic tract may be present.
The following case of glioma of the frontal
lobe illustrates a point of practical interest,
namely, that a highly cellular tumour of the
brain is not necessarily very malignant. This is
true, not of brain tumours only, but of tumours
of other parts of the body : thus a large cellular
carcinoma mammas may prove less malignant
than a small atrophic scirrhus with few cellular
elements.
In 1903 a man, aged thirty-two, was admitted into
the National Hospital under the care of Sir William
Gowers. Three years previously he commenced to
have peculiar attacks without loss of consciousness, in
which a choking sensation was experienced. Four
months previously he had his first Jacksonian fit, which
commenced with shaking of the right arm. On admis-
sion he had incomplete right hemiplegia, the arm being
most afi^ected, severe headache, slow speech, loss of
memory, mental dulness, impairment of sensation in
right hand and forearm, and in right foot and leg, and
early double optic neuritis. The condition of patient
rapidly deteriorated, vomiting occurred, and the optic
neuritis increased. I drained a large gliomatous cyst
in the left frontal lobe with complete relief of symptoms.
OF TUMOUR OF THE BRAIN 317
Two years later the symptoms recurred, and I then
removed a large mass of tumour from the same region.
The patient left hospital well and proposed to resume
his work. The tumour was a highly cellular glioma.
(Fig. 166.)
Illustrative Cases.
1. Brissaud and De Massary's Case. Fits and
persistent Headache.
Male, aged twenty-eight years. On July 10, 1894,
had an epileptic fit without any apparent cause; the four
following days he went to work as usual. The fits were
afterwards repeated, and besides the complete attacks,
in which the convulsions were generalised and conscious-
ness was lost, he had at intervals abortive attacks, the
facial muscles twitched, the countenance was distorted
by a forced grin, and the patient, though conscious and
understanding what was said to him, could make no
reply. He improved, but in January 1895 the com-
plete attacks recommenced. The movements were
greater on the left side than on the right. In the
intervals between the attacks the patient complained of
headache and throbbing referred both to the frontal and
the occipital region. There were no visual troubles,
and there was no optic neuritis. Bromide was given,
and the attacks became less frequent; in May 1895,
renewed frequency of attacks with rise of temperature.
Similar treatment with the addition of antipyrin ; the
patient again improved and returned to work. In
January 1896 he had a relapse, followed shortly by
death. At the autopsy a sarcoma of the pia mater was
found, 6 by 3 cm., involving the first and part of the
second frontal convolutions on the right side. The
3i8 SOME POINTS IN THE SURGERY
tumour was adherent to the dura mater, and had
sprouted through several little rents in that membrane.
Brissaud and de Massary, in commenting on the case,
observe that headache sometimes occurs as a more or
less persistent symptom in aged epileptics with athero-
matous arteries, but that as a rule a diagnosis of essential
epilepsy should exclude persistent headache. Persistent
headache, even though diffused, should be considered a
formal indication for operation, particularly if it becomes
aggravated when the fits occur. Even though no tumour
may be found, a decompressive operation will prevent
the occurrence of a fatal status epilepticus.
//. Knechfs Case. Fits and Emprosthotonos.
Male, aged twenty-seven years. In 1876 began to
increase in weight, and in October of that year began to
suffer from convulsions, preceded by headache and pain
in the back of the neck.
The attacks began suddenly by the head being bent
forwards, urine was passed, and vomiting occurred
during the attacks, and the trunk was bent strongly
forwards. Consciousness was not entirely lost. A
somnolent condition followed the attacks. In March,
during two attacks, the muscles bending the head and
trunk forwards remained strongly contracted. The
patient complained of pain in the muscles of the neck
and in the frontal region. In April and May similar
attacks. On May 19, paresis of left external rectus
observed, and the tongue and the uvula deviated to the
left. On May 23 he had frequent attacks and could
not see ; when he got out of the room he could not
find it again ; the next day he died. Rigor mortis
occurred a few minutes after death. The dura over
OF TUMOUR OF THE BRAIN 319
the left hemisphere was very tense. Over the frontal
region it was adherent to the pia. A glioma as large
as a pigeon's egg was found at the tip of the left frontal
lobe, involving the first and second frontal convolutions.
The whole left hemisphere was hyperasmic.
III. Cestan and Lejeune s Case. Fits., Paralysis.^ Mental
Symptoms^ and partial Aphasia.
A woman, aged thirty-three years, was admitted to
hospital with right hemiplegia, complete blindness,
mental disturbance, headache, vomiting, fits, optic
neuritis, and partial aphasia.
The symptoms of increased intra-cranial tension,
headache, optic neuritis, and vomiting almost completely
subsided, and as this took place a peculiar defect in the
mental condition became manifest ; the patient had no
delusions, nor was she demented, but she seemed to
have lost the power of associating ideas and of attention.
She knew and recognised her relatives, the professors,
and those who attended on her ; but she could not be
induced to remember the names of any of the staff or
attendants, even of those who saw her daily. She would
make simple additions, but would not multiply. She
had almost complete loss of memory for recent events.
Fits continued at intervals, and always began at the
right angle of the mouth ; the reflexes were brisk.
Stereognosis and sensation were, so far as the defective
mental condition would allow them to be tested, normal.
The patient died, and a sarcoma of the meninges as
large as an orange, and surrounded by a zone of soften-
ing, was found in the left frontal region. The tumour
involved the posterior two-thirds of the 1st and 2nd,
320 SOME POINTS IN THE SURGERY
and the posterior extremity of the 3rd frontal convolu-
tions, and it also compressed and covered over the
ascending frontal convolution.
""^^M
^^M
1 -. ^^"i^^^jf&^^^^y^!^^
m
Fig. 167. — Glioma of frontal lobe. (Ballet and Delille, T902.)
A man, aged 53 years, poor and overworked, was admitted to the Salpetriere on
October 8, 1900. He had had migraine and neuralgia for a long time, and for six
months he had suffered from a sensation of emptiness in the head which was most
troublesome. On September 20 he had incontinence of urine, and on October i
right hemiparesis, with some difficulty in articulation. He was a painter, and
confused the names of his pictures and of the parties to whom he had sold them.
His disposition, normally violent, had become more gentle. On October 7 he had
incontinence of faeces for the first time. At this time he was mentally weak,
inclined to melancholy, and easily became tired. Sight normal. Paresis of limbs
and lower half of face on the right side. The patellar reflexes were exaggerated.
Mental condition rapidly deteriorated. On November 1 1 he became comatose, and
died the following day. The temperature rose to ii6°.7 immediately before death.
^t the autopsy a large glioma, which was not encapsuled, but incorporated with
the substance of the hemisphere, was found occupying the left frontal lobe. The
tumour measured 5^ x 6 x 3 cm.
Remarks. — Note that though the tumour is apparently discontinuous with the
brain on the surface, the section shows that there is no line of demarcation between
normal brain and tumour tissue. This is a most important point to bear in mind
at operations.
Ballet and Delille describe another interesting case of frontal lobe tumour : — •
Male, aged 19 years. Was struck a severe blow with a stick in the left temporal
region. The next day he had headache, and at the end of a week he had ptosis on
both sides, diplopia, amblyopia. Three days later all symptoms subsided except
ptosis on the left side and headache. These persisted, and two months later he
was admitted to hospital. It was then found that the sense of smell was somewhat
impaired on the left side. He had epileptic fits the day after admission. The deep
reflexes were exaggerated. Operation was advised, but refused. Five months later
he was readmitted with torpor and right-hand paresis. A diffuse glioma was found
on the inner aspect of the anterior part of the left frontal lobe.
OF TUMOUR OF THE BRAIN 321
Fig. 169.
Figs. T 68-1 70. — Large glio-sar coma of frontal lobe successfully
removed. (Keen and Thomas})
Fig. 168. — The tumour. It was 7.5 cm.
long, 5.5 cm. broad, and 4 cm. deep, and was
well defined. It weighed 2J oz.
Fig. 169. — Diagram to show approximately
the relations of the tumour, which is repre-
sented by the shaded area. The interrupted
line represents the osteoplastic flap. I., II.,
III., are the three frontal convolutions. Q5
represents the place where the tumour had
broken through the cortex ; R, fissure of
Rolando ; V, precentral sulcus ; IP, intra-
parietal sulcus ; S, fissure of Sylvius ; T,
temporal ridge.
Fig. 170. — Diagram to show the depth and
relation of the tumour to the convolutions and
the ventricle. The shaded portion represents
the tumour.
Patient a male, aged 17 years. History
of injury left frontal region. Headache,
vomiting, and dim vision from optic neuritis.
Slight weakness right face. Left eyeball
prominent. Mental dulness. No fits, hence
probably subcortical tumour. Later some weakness of right hand and thickness of speech. The tumour
was shelled out without difficulty. The anterior part of the ventricle was packed to prevent blood
passing into it.
Keen refers to seven other tumours larger than the one above described, which have been removed
from the brain. His first case, operated on in 1887, was published in the American Journal of the
Medical Sciences for 1888. The operation was successful. The tumour was a fibroma occupying the
left frontal region. It weighed 3 oz. and 49 grains.
Fig. 170.
322 SOME POINTS IN THE SURGERY
Front.
I
Fig. 17J
Fig. 17 2.
Outer surface.
Fig. 173.
Outer
surface of /r
hemisphere, .ii
Fig. 174.
OF TUMOUR OF THE BRAIN 323
Figs, 171- 174. — Figures illustrating a case of Sub-
cortical Tumour (^Cystic Angio- Sarcoma) which
commenced to grow in the Centrum Ovale beneath
the lower part of the Motor Cortex.
The patient was a boy aged ii years. One year before admission to hospital
under Sir William Gowers he was stunned by a blow on the left side of the head ;
this was followed by irritable temper. The other salient facts of the case were as
follow : —
1. Fits commencing with twitching of the right angle of the mouth, and followed
by paralysis of the lower part of the right face.
2. Gradual extension of the paralysis to the right upper and lower extremities.
No hemianaesthesia.
3. Slow speech. No tender spot on cranium.
4. Severe frontal headache, vomiting, and double optic neuritis.
First Operation. — A drainage tube was inserted into the cyst, with the result that
all the symptoms were relieved. The cyst lay under the lower part of the ascending
parietal and frontal convolutions, and extended forwards beyond the ascending frontal
convolution for about I inch. On looking into the cyst the wall appeared like
normal brain tissue j there was no true cyst wall. The drainage of the " cyst " was
sometimes good and sometimes obstructed. The fluid being plasma, blocked the
tube on cooling 5 hence repeated difficulties in drainage were encountered. When
drainage was good the symptoms disappeared, and wee -versa. Three years and three
months from the first operation the child grew worse, and the —
Second Operation was done, a cystic tumour 3 oz. in weight being removed.
Fig. 171 is a photograph i\ months after the removal of the tumour. During the
hve. months preceding the operation the boy was detected on many occasions stealing
from other patients in the ward with much cunning. After the removal of the
tumour this moral deterioration disappeared.
Five months after removal of the tumour, patient was admitted with a large
cerebral hernia (Fig. 172) coming through the cranial opening and bulging the scalp
flap.
Third Operation. — ^The bulging mass was found to be a large timiour. The bone
around the cranial opening bled from every pore, and all efl^arts to stop this capillary
haemorrhage from the infected bone failed. The child died a few hours later.
Figs. 173 and 174 are horizontal and coronal sections of the left hemisphere. The
enormous extent of the tumour is very remarkable j it commenced in the left frontal
lobe, and grew gradually backwards, pushing before it the pyramidal fibres in the
corona radiata. Before the last operation the right hemiplegia was only partial.
Remarks. — This case occurred some fifteen years ago. The treatment should
have been enucleation of the tumour at the first operation.
324 SOME POINTS IN THE SURGERY
Figs. 175-182. — Malignant Growth of Frontal Lobe
perforating Dura and Skull.
F. S., male, under the care of Dr. Acland in St. Thomas's Hospital.
Previous History. — Never had syphilis, does not take alcohol, no history of injury
to skull.
Present Illness. — Seven years ago noticed swelling in right frontal region, which
has very slowly increased in size. About this time patient had a fit. Four years
ago he had another fit, and again two years ago. During the last eighteen months
he has had a good deal of headache, has occasionally done odd things, has not been
able to walk far, and has had occasional incontinence of urine.
Patient now complains of severe aching pain in right frontal region — which,
however, is not continuous — and some loss of sight, especially in right eye.
State on admission. — Smooth, hard swelling right frontal region, extending over
middle line, and involving right frontal, right parietal, right squamous, and left
parietal bones. The edge of the tumour is definite. The scalp is free over the
tumour, and there is no tenderness on pressure.
Mental state dull, speech slow, lack of power of attention, incontinence of urine
at night. No alteration of reflexes, no paralysis of limbs. No optic neuritis :
diplopia on looking to the extreme right or left. Headache absent as a rule in
morning, but comes on when he gets out of bed ; often severe in latter part of day
in frontal region.
Patient became rapidly worse in hospital — the mental torpor increased, and
sometimes he was difficult to rouse j the power of attention failed, answers to
questions were not completed, and he spilled his food over the bed. Ten days after
admission operation for the removal of the bone tumour was performed.
Operation. — -The bone around the tumour was cut through, as described under
Fig. 179. The capillary bleeding from the bone was in some places considerable,
which made me think I had to do with a sarcoma of bone. When the bone section
was completed it was found that the mass could not be raised from the dura, as the
central part of its under surface was attached to a growth coming through the dura.
This isthmus of tumour was torn through, and the finger being inserted through
the dural opening, discovered the anterior part of the frontal lobe replaced by new
growth.
The patient's condition now became suddenly very bad j the scalp wound was
rapidly sewn up, and infusion and other restoratives applied. Patient did not rally,
and death took place the next morning.
Remarks. — The operation was undertaken with the idea that the tumour was a
slow-growing sarcoma of bone, or that the bone tumour was of a nature allied to
leontiasis ossea. It was supposed that the tumour had encroached on the intra-cranial
cavity and compressed the frontal lobe, which would account for the mental
symptoms, the headache, and the incontinence of urine. Dr. Beevor has drawn
attention to the early occurrence of incontinence of urine in frontal lobe tumours.
Microscopical Appearances. — The mass of the growth was vascular and highly
cellular. In parts there were numerous whorls or groups of cells arranged concen-
trically. The greyish processes which extended between the brain and the frontal
bone were composed of longitudinally arranged blood channels without definite walls
around which the cells of the tumour ranged themselves. It is probable that the
growth commenced as a hasmangio-endothelioma in the frontal lobe, and later a
transition occurred into a more common form of sarcoma.
OF TUMOUR OF THE BRAIN 325
Fig. 175. Fig. 176.
Figs. 175 and 176. — Sarcoma of frontal lobe perforating dura and frontal bone.
Photographs of patient before operation.
326 SOME POINTS IN THE SURGERY
Fig. 177. — Photograph of external surface of the portion of skull, after maceration,
removed at the operation.
a, b, median line.
The measurements were 6 inches from before backwards, and 5 inches from side
to side 5 but when the tape was laid on the curve, the measurements were 7f inches
and 8 inches. Measured by callipers the thickness of bone in the centre was
i^ inches.
Note the coral-like appearance of the bone, due to infiltration with new growth.
OF TUMOUR OF THE BRAIN 327
Fig. I 78. — Photograph of internal aspect of the portion of skull, after maceration,
removed at the operation.
a, b, median line.
Extending from the opening in the dura to the central portion of the bone which
appears dark in colour, were long, string-like, grey-coloured processes of new growth.
3
28 SOME POINTS IN THE SURGERY
Fig. 179. — Photograph of the portion of skull, after maceration, removed at the
operation, viewed from the left side.
The trephine opening was made in the left parietal bone, and the remainder of
the skull section was made by powerful forceps of the de Vilbiss pattern.
Fig. 180. — Photograph of anterior part of brain enclosed in dural capsule, showing
sarcoma of right frontal lobe sprouting through the dura.
OF TUMOUR OF THE BRAIN 329
\
Fig. 181. — Photograph of brain enclosed in dural sheath, showing (from above) the
sarcoma of right frontal lobe sprouting through the opening in the dura.
Fig. 182. — Photograph of horizontal section of brain through the lower part of
the opening in the dura.
The brain, unfortunately, was not properly preserved.
It was impossible to photograph the sections made at a higher level, the brain
tissue being diffluent.
330 SOME POINTS IN THE SURGERY
Tumour of the Parietal Lobe.
The intra-parietal sulcus arches through the
parietal lobe. Its horizontal portion divides the
parietal lobe into two parts — the superior and
inferior parietal lobules. Its vertical portion
(post-centralis inferior) separates the post-central
convolution from the supra - marginal gyrus.
The superior parietal lobule is continuous on
the mesial surface of the hemisphere with the
quadrate lobule or precuneus. The inferior
parietal lobule is embraced within the curve of
the intra-parietal sulcus. It presents three
arching convolutions — the supra - marginal,
angular, and post-parietal convolutions. With
regard to the ascending parietal convolution and
the superior parietal lobule Mills writes : —
" Physiologically this part of the cortex can be
divided into areas of cutaneous and muscular
sensibility and of stereognostic perception.
Muscular sensibility has its representation in the
anterior part of the superior parietal lobe and
the anterior part of the inferior parietal lobe
(supra-marginal convolution). Cortical sensory
representation is probably divided into segments
for different cutaneous areas of the body, and
these have topographical relations with centres
OF TUMOUR OF THE BRAIN 331
and sub-areas of the motor region. Stereognosis
is a conceptual process. The ability to recognise
objects by touching and handling them so as to
obtain an idea of their form is brought about by
the recalling of memorial images obtained in
the first place through such senses as contact,
pain, temperature, spacing, location, and posi-
tion ; but although thus obtained, the process of
recognising objects in this way becomes an
independent one. The cutaneous and muscular
processes are primary ; stereognosis is secondary
and higher." In one of Dr. Beevor's cases, in
which pachymeningitis involved the right
cortex over an area including the lower half of
the ascending parietal gyrus and the whole of
the supra -marginal convolution, the patient, a
man aged forty-two years, suffered from diminu-
tion of common sensation, loss of the power of
localising light touches, and loss of muscular
sense in the left upper limb.
The growth of a tumour is so seldom re-
stricted to the part of the parietal area in front
of and above the intra - parietal sulcus, that
besides the symptoms due to the loss of the
cortical representation of the various forms of
common sensation, including the localisation of
tactile impressions, muscular sense, and stereo-
gnostic perception, other symptoms, such as
332 SOME POINTS IN THE SURGERY
follow involvement of the motor region, are
usually present.
The angular gyrus and the post - parietal
gyrus form part of the higher visual field, and
on the left side are concerned in the higher
nervous mechanism of language. Tumour in-
volving the angular convolution gives rise to
inability to comprehend the visual symbols of
ideas, such as words, letters, numbers, musical
notes, gestures, etc. If the tumour involves the
post-parietal convolution, objects though seen
will not be recognised ; this symptom is spoken
of as object or mind blindness. If the tumour
also involves the posterior end of the superior
temporo - sphenoidal convolution, in the grey
matter of which are the cortical centres for
hearing, cortical deafness or auditory amnesia in
its various varieties are present also.
Duret insists upon the connection of the
superior parietal lobule and its mesial annexe,
the quadrate lobe, with the representation of
superficial and deep sensation and stereognosis,
and that the inferior parietal lobule plays an
important part in the faculty of language, par-
ticularly in word -seeing, and consequently in
reading and writing. Hence lesions of this
region on the left side give rise to sensory
agraphia, alexia, and amusia.
OF TUMOUR OF THE BRAIN 333
A particular motor defect which has been
termed " apraxia," has been met with in lesions
of one or other parietal lobule. Duret terms it
a psychic paralysis, but Liepmann, who described
the condition, considers that it is quite distinct
from psycjiic paralysis, and that it bears the
same relation to the muscles of the limbs that
motor aphasia does to the muscles of the organs
concerned in speech. The patient knows per-
fectly well what he desires to do, but is unable
to make the appropriate systematised movements ;.
though the limb affected (say the arm) is not
paralysed and not ataxic, he either makes no
movement at all, or makes the movement appro-
priate to an entirely different purpose ; thus an
apraxic wishing to smoke a cigar made the
movements appropriate to the use of the tooth-
brush, just as an aphasic, though well aware
what he wishes to say, employs a word of quite
a different meaning.
Liepmann's explanation of the meaning of
apraxia is as follows : —
A lesion interfering with the transmission of the
centripetal impulses that arise from the position of the
joints, the degree of tension of muscles, tendons, and
fascial bands, and certain impressions from the skin,
which together make up the so-called muscular sense,
or damage to the cortical sensory centres where such
impulses are received, gives rise to ataxia. The patient
334 SOME POINTS IN THE SURGERY
is no longer able, as normally, to control his movements
through the sensation of the position and of the move-
ment of the limbs ; coarse movements are performed,
though clumsily ; but more delicate movements, such
as fastening a collar button, are impossible. The
desired act cannot be performed owing to failure of co-
ordination of the elementary muscular movements, the
limb moving in jerks or being carried wide of the mark.
In apraxia the combination of co-ordinated movements
for a definite purpose fails, an effect quite different
from the one desired being brought about, though the
movements themselves are perfectly co-ordinated ; for
example, an ataxic would use a comb clumsily enough,
but always as a comb — not, as did an apraxic, like a
pen or a Jew's harp.
Liepmann considers that the phenomenon of
apraxia is explained by the existence of a lesion
or lesions which cut off the cortical sensori-
motor nervous mechanism from the higher
special sense centres, especially the optic and
auditory perception centres, through which
most of the movements we are accustomed to
perform are initiated, directed, and controlled.
By the habitual performance of a certain act the
sensori-motor nervous mechanism in the cortex
becomes so adjusted that the sensory impressions
resulting from the position of the muscles and
joints concerned in each phase of the act are able
to call forth the motor impulses for the succeed-
ing phase, the current of energy being, so to
OF TUMOUR OF THE BRAIN 335
speak, short-circuited at the sensori - motor
cortical area, so that the act once started is
continued sub-consciously, though not sub-
cortically ; for the initiation and the proper
control of any act, not only must the cortical
sensori- motor mechanism be intact, but its
connections with the higher perception centres
must be maintained.
Just as interruptions of the normal communi-
cations between the highly specialised portion
of the sensori-motor nervous mechanism of the
cortex and those portions of the perception
centres concerned in language gives rise to
aphasia in various forms, so interruption of the
normal nervous connections between the larger
sensori-motor cortical area and the higher per-
ception centres causes disorder in the performance
of definite purposeful acts. Apraxia like aphasia
may be more or less complete, and affect certain
acts only : no trace of any purposeful action
may be evident in the movements executed, or
certain definite elementary phases of a purposeful
act may be manifest, or the movement may be
definitely purposeful though not adapted to the
particular act it is desired to perform ; just as an
aphasic may utter sounds bearing no resemblance
to articulate speech, or definite syllables may
be recognisable though not combined to form
336 SOME POINTS IN THE SURGERY
words, or definite words may be uttered, but not
meaning what was intended.
Tumours of the parietal region, extending
inwards, reach the posterior end of the internal
capsule ; and thus other symptoms arise, such as
hemianopsia, hemianassthesia, and hemiplegia.
Illustrative Cases.
/. Bruns' Case. Sensory Symptoms from Tumour
involving Superior Parietal Lobule.
A man, aged iifty-five years, began to fail in health.
In October 1896 he had slight vertigo, mental fatigue,
and irritability. In November he had a fall on the
right side. In February 1897 optic neuritis and com-
mencing right hemianopsia were observed, together
with sensory disturbances on the right side of the body,
especially in the arm. The symptoms increased in
severity ; the sense of stereognostic perception was first
lost, then that of position of the limb, and, lastly, sense
of pain and of contact. In consequence the movements
of the right upper limb, especially of the hand, were
very unsteady when the eyes were shut. Neuralgic
pains preceded the loss of sensation. The right hemi-
anopsia became complete by the end of November 1897.
There were slight and variable language defects, the
hemianopsia interfered somewhat with reading, but
there was no true alexia. Of the general symptoms of
tumour, vertigo was first noticed, then optic neuritis ;
for a long time there was neither headache nor vomit-
ing ; headache was not complained of until January
1898, and was chiefly occipital, while vomiting only
OF TUMOUR OF THE BRAIN i^i^j
occurred shortly before death, and then on but few
occasions. The patient never had convulsions, but had
apoplectic attacks, sometimes accompanied by temporary
total blindness, and on one occasion there was temporary
right ptosis lasting twelve hours. The patient died on
May 4, 1898.
At the autopsy a hard encapsuled meningeal tumour
was found, measuring 6 by 4.5 by 4 cm. It was quite
sharply differentiated from the brain substance, but had
hollowed out and compressed the left superior parietal
lobule. It protruded through an aperture in the dura
4 cm. in diameter, and was only adherent to the dura
at the edges of this opening. The pia mater ceased at
the edge of the hollow in the brain in which the
tumour lay. Microscopical examination showed that
the grey matter beneath the tumour was destroyed by
atrophy and softening. The growth was a sarcoma
which Bruns considered had sprung from the inner
surface of the dura.
The account of this case by Bruns, and his observa-
tions thereon, are instructive. His localisation of the
growth was exact, but he was of opinion that it was in
the white matter of the brain, whereas the autopsy
showed that, like the growth shown in Fig. 104, it was
meningeal, and could have been removed by operation.
He inferred that the growth was deeply seated, because
(i) headache was absent in the initial stages ; (2) there
was no tenderness on percussion of the skull ; and
(3) that hemianalgesia was present, which he thought
rare from a purely cortical lesion, though astereognosis
points especially to involvement of the cortex. The
temporary blindness he attributed to sudden increase of
intra-cranial tension leading to pressure on the optic
chiasma. The fall mentioned in the history of this
z
33B SOME POINTS IN THE SURGERY
case was due to the tumour, not the tumour to the fall.
Many observations have been made during the eight
years that have elapsed since the publication of this case,
tending to increase our appreciation of the localising
value of cortical sensory affections, and it seems clear
that the rule should be that any patient presenting
symptoms of such definite localising value should have
the chance afforded by an exploratory operation.
//. Raymond ' s Case. Loss of Sensation : no Loss of
Motor Power till Late in the Illness.
A man, aged forty-seven years, employed in the
post office. The illness began with a feeling of
numbness and heaviness in the left hand, and he soon
became unable to oppose the thumb to the fingers, and
consequently had great difficulty in sorting letters.
He was unable to take up and adjust the dynamometer,
but when it was placed in his hand he was able to grasp
it with a force equal to that of the other hand. Sensa-
tion, particularly deep sensation, became more and
more impaired in the left upper limb ; finally, the hand
lost all sensation of weight, of position, and of tempera-
ture, so that it was hypoassthetic and ataxic. The left
supinator jerk was increased. The general signs of
brain tumour gradually manifested themselves ; head-
ache, at first general, became localised on the right
side. The diagnosis was large glioma not definitely
limited, which could not be removed. The patient left
the clinic soon after Prof. Raymond's lecture, and the
ultimate result is not known.
In his comment on this case Prof. Raymond re-
marks that loss of sensation from cortical lesion is
(i) rarely total; (2) especially affects the muscular
OF TUMOUR OF THE BRAIN 339
sense, the sense of temperature, and the different
varieties of deep sensation which go to form stereo-
gnostic perception ; (3) rarely extends to the whole of
one side of the body, and still more rarely is uniformly
intense over the whole area affected. It is a hypo-
assthesia rather than an anassthesia, and is often limited
to one limb, or even to a segment of a limb. Also that
while in some cases Jacksonian epilepsy is the dominant
symptom, in others the convulsions are abortive, and
are but a fragment of the symptoms present, and apt
to be lost sight of and as it were smothered in the
other manifestations. Such abortive attacks of
Jacksonian epilepsy may, nevertheless, if carefully ob-
served, be an important guide to the seat of the lesion.
The convulsive attacks were in this case abortive, hence
Raymond thought it probable that the lesion did not
directly affect the cortical motor centres, but only the
fibres of conduction leading therefrom. Cortical ataxia
does not occur without loss of deep sensation. Co-
ordination depends on the exact correlation of the
activity of the sensory and motor centres, and is not
the function of a special part of the cortex. Raymond
further insists that great improvement under anti-
syphilitic treatment does not necessarily indicate that
the lesion is syphilitic. It may be due to the resolvent
effect of iodide of potassium and mercury on the
inflammation around a malignant tumour.
///. Lemos s Case. Localisation determined by
Sensori-motor Aura.
A man, aged twenty-four years, all of whose family
showed signs of an irritable, nervous system, suffered at
frequent intervals from generalised convulsions with
340 SOME POINTS IN THE SURGERY
loss of consciousness. The fits were preceded by a
peculiar aura ; the patient felt pain in the head, with a
feeling of irritability and depression, accompanied by
a sensation of stiffness or contraction gradually creeping
up the left leg. He had no loss of power, but com-
plained of pain in that limb, and later on had frequent
hallucinations as to its position and shape. On several
occasions he told his doctor he had twisted it, and
asked him to reduce the deformity. Muscular sense
was quite lost, so that if the eyes were closed and the
limb moved passively, the patient had no sense of its
position. He died in the " status epilepticus," and at
the autopsy a solitary tubercle no larger than a pea was
found in the right superior parietal lobule close to its
junction with the ascending parietal convolution.
IV. Starr and M^ Cosh's Case. Loss of Muscular Sense
and Astereognosis without Motor Symptoms.
" The muscular sense, or sense of position of limbs,
as derived from sensations arising in the surface, joints,
and muscles, which serve as a guide to movement "
(S. and M.).
Male, aged twenty-one years, had a fall on the head
at five years, and a second at sixteen years of age ; was
unconscious on both occasions. He complained of pain
in the left side of the head, referred to a spot where
there was a small scar between the parietal eminence
and the middle line of the vertex. The pain was con-
tinuous with exacerbations. The patient was subject to
maniacal attacks, with, at times, loss of consciousness,
which had prevented him from having regular educa-
tion or following any employment. He was trephined
in the region of the scar ; a linear depression was found
OF TUMOUR OF THE BRAIN 341
in the bone on its outer surface, but no fracture of the
inner table. On opening the dura no evidence of
meningitis was seen. There was a vascular mass con-
sisting exclusively of veins immediately beneath the
trephine opening. The opening in the skull was en-
larged, and the mass removed after ligature of the
vessels leading into it. The cortical grey matter was
slightly injured in placing the ligatures. After removal
of the mass the cortex was explored with a needle, but
no fluid was found. Immediately after the operation
the boy had a peculiar awkwardness of the right arm
and hand. There was pronounced ataxia, and when
the eyes were shut and the right arm moved passively
the patient was unable to place the left arm in the
corresponding position. The actual power of the right
hand was greater than that of the left. This condition
lasted unaltered for about three weeks, and then gradually
subsided ; the ultimate recovery was complete. The
lesion was considered to involve the cortex above and
below the intra-parietal sulcus,
V. Spillers Case. Sensation and Stereognostic Perception-
impaired in one Limb without other Symptoms.
Male, aged thirty-eight years, a teacher. Was well
until July 21, 1904, when he had a blow over the right
parietal region which rendered him unconscious for two
hours. He was unable to use the fingers of the left
hand for two weeks after the blow, and since the injury
had parassthesia of the left hand. There was no affec-
tion of the face or of the lower limb. The sense of
position and stereognostic perception were much im-
paired in the left hand, and the answers to sensory tests
of that region were less accurate than to corresponding
342 SOME POINTS IN THE SURGERY
tests on the opposite side. The ultimate result is not
stated.
VI. Kortewegs Case. Alexia^ Agraphia, Aphasia,
diffuse infiltrating Tumour of Inferior Parietal Lobule.
Man, aged twenty-six years. In February 1899
began to suffer from headache, and at times used words
incorrectly while speaking. Admitted to hospital the
following May ; he then had violent headache, optic
neuritis on both sides without loss of vision, paresis of
right fourth nerve, and slight right hemiparesis with
parassthesia, particularly in the fingers. Light touches
on the right arm and right foot were incorrectly localised,
sense of position of the right fingers lost, and passive
movements not appreciated. Patient heard names and
words, but understood the latter imperfectly. Particularly
when tired he would reply to a question by repeating the
answer he had given to a previous question. He saw and
recognised objects ; he could see letters and words, but
could not read words, whether in scrip or print, particu-
larly if they were a little long. He spoke a good deal,
and had many words at his command, but occasionally
made mistakes. He could not repeat long words or
even simple sentences. He had a peculiar tendency to
mingle words previously heard or said ; thus, having said
"red," "lottery ticket," he said "re-lot," and having
said "red," "lead," "inkstand," he said "re-linked."
He read aloud very badly, but could repeat letters, and
even short words well enough, but could only get out
the first words of a long phrase. Spontaneous writing
was impossible to him, and in writing from dictation he
only succeeded in writing the initial letters correctly ;
he could copy correctly, whether from scrip or from
OF TUMOUR OF THE BRAIN 343
print. Diagnosis : tumour of left parietal lobe involving
the gyrus angularis. Operation ; sarcoma found, which
could be only partially removed. Made a good recovery
from operation ; headache and optic neuritis got better,
but paresis of motion and sensation on right side worse
than before. Aphasic symptoms much better, but no
improvement in writing. Later symptoms aggravated,
and flap bulged ; more growth removed in September,
headache again relieved, but soon returned. November
26. — -Third operation ; headache again relieved, but
death eight days after. No autopsy. (Quoted from
Chipault.)
VII. Liepmann s Case. Apraxia.
A man, aged 48 years, who had had syphilis nineteen
years previously, began in the summer of 1899 to suffer
from vertigo and attacks of faintness and pain in the
occipital region. He soon became unable to attend to
his official duties. (He held an administrative post.)
When speaking he often came to a stop, lost the thread
of what he was saying, and frequently contradicted
himself. He also made mistakes in writing. He
became forgetful, and lost his way in going about the
streets. On December 2, 1899, he had a fit without
loss of consciousness, after which he was aphasic and
for a time unable to walk, though he had no paralysis
of limbs.
He wrote, fed himself, and fought duels right-
handed, but always played cards left-handed.
On December 7, 1899, ^^ ^^^ admitted to hospital.
He then seemed almost completely demented, passed
urine and fasces in bed. There was left facial paresis.
Power of speech and writing lost. Urine contained
344 SOME POINTS IN THE SURGERY
i^ per cent sugar. In a month he improved consider-
ably, but was still aphasic, could only say "ja" and
*'ach," and once got out " Donner-wetter," Some-
times seemed to recognise objects, at others not. On
January 13, 1900, he was able to write his name with
the omission of one or two letters, and had learned to
write the word " knife " ; for some time afterwards,
whenever he attempted to write, this word came from
his pen. On January 30 he ran away, and was found
wandering in the streets ; the next day he was taken
home by his wife. Ten days later he was admitted to
an asylum with the diagnosis, " Aphasia and dementia
following apoplexy."
On February 17, 1900, seen by Liepmann for the
first time.
The patient was asked to make certain movements
with the hand, and to pick up a particular one of a
number of familiar objects that were on the table before
him. He invariably made the attempt with the right
hand, but was always wrong, and the way in which he
handled the objects was altogether absurd.
At first sight it seemed that the patient was word
deaf and perhaps also object blind. When asked to
execute a movement in which the whole body was con-
cerned, such as to stand up, to go to the window or
the door, the patient did so without any hesitation or
difficulty ; the power of understanding speech was
therefore not wholly lost. Liepmann then suspected
that the errors made with the right hand depended on
a purely motor defect and not on any want of compre-
hension. He then held the right hand of the patient
firmly, and asked him to hand up one of the objects
lying on the table ; he at once did so, and made no
mistake so long as he was compelled to use the left
OF TUMOUR OF THE BRAIN 345
hand. He, however, always made mistakes when allowed
to use the right. The right leg was similarly affected ;
the patient could imitate any movement with the left leg,
but none with the right. It was at once clear that the
patient was neither word deaf nor object blind.
Liepmann during the next few weeks made a careful
study of the patient's condition, for a full account of
which the original paper must be consulted ; only a
short summary can here be given.
The patient had almost complete motor aphasia ; he
could only say a few monosyllables, and did not use
those appropriately. His right-sided apraxia gave him
the appearance of being unable to understand writing ;
but as he could execute correctly a written request
when he was compelled to use the left hand, it was
clear that he could understand writing. Short written
requests were equally well understood, whether written
in German or in French, but long written sentences
were not understood. It was found that he had lost
the power of expression by gesture as well as by speech,
so that a nod or shake of the head could not be de-
pended upon for " yes " and " no." When asked to
express " yes " by a plus sign and " no " by a minus
sign made with the left hand, the answers were reliable,
and so a way of communication was opened.
With the right hand he could neither write spon-
taneously nor copy, a few letters, " m " most often, and
those misplaced were occasionally recognised in the
scribble. He could not copy simple geometrical figures
with the right hand.
With the left hand he wrote what at first sight
seemed meaningless scribble ; but on looking more
closely it could be recognised as reversed writing, and
though the letters were clumsy, with the aid of a
346 SOME POINTS IN THE SURGERY
mirror the correct intention could always be traced.
Simple geometrical figures were clumsily copied by the
left hand, but in their general outline correctly.
Sensation was somewhat impaired in the right limbs ;
the power of localising needle -pricks was very im-
perfect, and the sensation of position of the right limbs
almost wholly lost.
The most striking feature of the case was the
apraxia of the right limbs ; this was most carefully
investigated by Liepmann. The patient could perform
certain acts to which he was accustomed perfectly well,
such as buttoning and unbuttoning his clothes with his
right hand, whether with the eyes shut or open. If
asked to button his coat, he had great hesitation and
difficulty in finding the button and commencing ; but
when once he had got the button and buttonhole, the
rest of the act followed smoothly enough.
He could smoke a cigar when once it was lighted
for him (using his right hand), but sometimes put the
wrong end in his mouth.
Given a comb and asked to use it, he took it in his
right hand, made various movements, rubbed the back
of it over his hair, and then stuck it behind his ear like
a pen. Asked to comb himself with his left hand, he
did so easily. It never seemed to occur to him to use
his left hand ; it was always necessary to ask him to do
so, or to hold his right hand.
Given a pen and asked to take a dip of ink, he
looked for the ink-pot, and when he had found it
placed his hand on it and put the pen down ; lifted up
the ink-pot, then put it down, and took up the pen ;
then put the cover on the ink-pot, and said " ach je."
Asked to do it with his left hand, he did so immediately.
When asked to do anything requiring the use of
OF TUMOUR OF THE BRAIN 347
both hands, the most grotesque effects resulted from
the irregular action of the right hand. For example :
Asked to transmit a telephone message, he took the
receiver with his left hand and placed it correctly to his
ear ; but he moved the transmitter to and fro with his
right hand, placed it to his forehead and made nodding
and puffing movements, then he put it to his eye and
looked into it, next he put it up to his mouth, and finally
placed it behind his ear. Asked to take up a box of
matches and strike a light, he took the box, and with
some difficulty opened it with his right hand, took out
a match with the left hand, and held it ready to strike ;
but instead of holding the box firmly with the right
hand, he moved it about, put it down, then took it up
again, and finished by putting it up to his mouth.
When the box was held for him, he struck the match
promptly with his left hand. Asked to brush the
professor's coat, he held the lappet of the coat correctly
with his left hand, but moved the brush with his right
hand up and down behind his ear. Asked to pour out
a glass of water, he took the jug in the left hand and
handled it correctly, but took up the empty glass with
his right hand and put it to his mouth ; when the glass
was held for him, he filled it without difficulty.
There was no affection of any special sense.
The muscles moving the head, face, and tongue
were apraxic on both sides ; the patient was amimetic
or paramimetic^that is, his facial expression underwent
no change with emotion, or assumed the expression
corresponding to a different emotion from that felt.
In addition to this defect, which was part of the aphasia,
there was definite apraxia, for he was unable to put out
his tongue, though it moved perfectly in mastication,
or to make a facial movement on request, whether the
348 SOME POINTS IN THE SURGERY
request was to make a definite movement such as to
wrinkle the forehead, or merely for a change of
expression such as to make a wry face.
The patient was treated by mercurial inunction, and
for several months improved considerably ; the power
of appreciating the position of the right limbs was
regained, and the sensation returned almost to the
normal, but the apraxia persisted, though in a some-
what less degree. The patient by making more use of
his left hand became much less helpless.
In October he had an apoplectic attack, which left
him with right hemiplegia and aphasia. Rapid im-
provement with inunction treatment. In December
he was able to speak again, though very indistinctly.
In January 1901 speech again lost. The arm had
recovered power of movement, but was ataxic as well
as apraxic ; the leg remained paretic. At the end of
1 90 1 the left hand became in some degree apraxic ; in
May 1902 the patient had three fits and complete left
hemiplegia. He never properly rallied, and his death
was hastened by pneumonia.
Autopsy. — Advanced arterio-sclerosis of the large
arteries of the brain, especially the left Sylvian artery
and the basilar. There was a trough-like depression of
the left supra-marginal convolution and superior parietal
lobule ; the convolutions affected were atrophic, but quite
distinct ; beneath them was a large cyst, the posterior ex-
tremity of which reached the white substance of the
gyrus angularis, but did not extend below it. The
precentral convolution was quite intact, and the post-
central convolution was apparently normal, except for
a small patch of yellow softening and a tiny cyst. In
the left insula was a small cyst. Broca's convolution
was atrophic. In the white substance of the left frontal
OF TUMOUR OF THE BRAIN 349
lobe was a patch of degeneration. The corpus callosum
was atrophic, and its anterior end contained a small cyst.
In the right hemisphere there was a small symmetrical
focus of disease in the gyrus angularis involving both
white and grey matter, and a patch of softening as large
as a pea in the internal capsule, which had probably
caused the left hemiplegia.
Remarks. — The large lesion in the left hemisphere
was in the region diagnosed as diseased by Liepmann
in an early stage of the case. The multiple lesions
found at the autopsy must have interfered considerably
with many association fibres.
350 SOME POINTS IN THE SURGERY
Fig. 183. — Left hemisphere.
Fig. 184. — Right hemisphere.
OF TUMOUR OF THE BRAIN 351
Figs. 183, 184. — Symmetrical cortical lesions causing
hallucinations of hearings word deafness^ and sensory
aphasia. [Serieux and Migot.)
The patient was a man, aged 41 years, who hati had syphilis at the age of 20
years. He was admitted to the asylum of Ville-Evrard on August 31, 1900. His
general intelligence was not much enfeebled, but he had delusions of persecution
and of grandeur which had become systeniatised under the influence of affections
of special sense. On several occasions this systematised delirium, based iipon
hallucinations, was temporarily interrupted by epileptiform convulsions 5 these
manifestations of abnormal excitation suddenly giving place to manifestations of
reduced activity of the corresponding centres, cortical deafness, then word deafness.
These symptoms lasted a few days and then gradually disappeared, and the hallucina-
tions of hearing — an almost constant symptom in the case — resumed their former
activity. In January and February 1901 he had a fresh series of convulsive attacks,
and the hallucinations became worse. In April and May word deafness, paraphasia,
jargonophasia, word blindness, and paragraphia were observed. These symptoms, as
in the preceding attacks, were of short duration ; but the intelligence was by that
time much enfeebled, and the hallucinations had become stereotyped. In June and
in October fresh series of convulsive attacks. The patient became violent and
agitated, and more and more demented ; the nutrition failed, and he died on
December i, 1901.
Autopsy. — Only the brain was examined. The right hemisphere weighed 551
grammes j the left, 521 grammes. This difference was due to atrophy affecting the
hemispheres unequally ; the patient was not left-handed. The meninges at the base
were slate-coloured. The pia was adherent to the cortex in places over both frontal
lobes, but these adhesions were of no great depth or extent. In both temporal lobes
there were scattered patches of slight ulceration, but in the left hemisphere in
addition there was a focus of intense meningo-encephalitis affecting the posterior
third of the first temporal convolution and the convolutions of the posterior inferior
part of the parietal lobe behind the intra- parietal sulcus. In this situation the lesion
extended in depth as far as the white substance ; the whole thickness of the grey
matter came away adherent to the pia. On the right side there was a symmetrically
placed, but less intense lesion, not reaching the white matter.
352 SOME POINTS IN THE SURGERY
Fig. 185. — Sketch of operation for subcortical tumour (sarcoma), growing in the
centrum ovale beneath the cortex of the upper part of the precentral convolu-
tion and the superior parietal lobule. (Beevor and Ballance.)
R, fissure of Rolando + place where cortex was thinned and ruptured during
palpation. The continuous line is the line of incision of cortex for removal of
tumour ; outside this the vessels have been ligated with fine silk.
Female, aged 30. Illness commenced twelve months before.
The salient points of the case were as follow : —
1. The gradual onset of the paralysis, involving successively ankle, knee, hip,
hand, elbow, shoulder, speech.
2. The syndrome symptoms were present — headache, vomiting, and optic
neuritis.
3. The mental condition deteriorated.
4. Partial loss of sensation in the right limbs.
Patient never had a fit, and there was no tenderness of cranium. Muscular
sense was lost in the right upper extremity and in the right toes and ankle.
Cutaneous sensation of all forms was affected, but not completely lost anywhere
on the right limbs or right half of the body.
The localisation of the tumour was easy— the absence of fits and cranial
tenderness pointed away from the cortex ; the march of the paralysis corresponded
to the arrangement of the representation of the different segments of the body
in the internal capsule, and the absence of complete anaesthesia was against cap-
sular destruction. On the mesial aspect of the hemisphere the tumour involved
part of the marginal convolution and quadrate lobe. The opening made in the bone
was 3^ X 2^ inches. After the removal of the tumour a large cup-shaped cavity,
the size of half an orange, was present in the brain, exposing a considerable area of
the falx.
The patient was able for three years to perform her household duties. Recur-
rence then took place, and a tumour weighing over 3 oz. was removed. Three
years later (six years from the first operation) recurrence again took place, but
patient died shortly after 3rd operation, of capillary haemorrhage from the bone
which had become infected around the edges of the cranial opening.
OF TUMOUR OF THE BRAIN 353
Fig. 188.
Figs. 186-189 illustrate the usual method of making the scalp flap, and the drainage of a malignant "cyst."
(Colman and Ballance.)
Fig. 186. — Scalp flap thrown down. A quadrilateral opening in the sliuU has been made. So great is the
intra-cranial pressure that the meningeal arteries are empty. The dotted line on the scalp is over the
sagittal suture.
Fig. 187. — Second stage of operation. Flap of dura has been turned down. I marks the intra-parietal
sulcus, S the Sylvian fissure. The cortex of the inferior parietal lobule is thinned, almost translucent
towards the centre, and forms the external boundary of the "cyst."
Fig. 188. — Lateral view of brain after hardening. The shaded cortex of the inferior parietal lobule
and of the posterior part of superior temporo-sphenoidal convolution is infiltrated by the tumour.
Fig. 189.— Transverse section of brain through AB in Fig. 188. The section passes through the centre
of the " cyst," and shows the path of drainage from the surface of the cortex. The extent of tumour
infiltration is shown by the shading.
Mrs. G., aged 31. Ten months before being seen had a fit. Other symptoms were severe headache, occa-
sional vomiting, optic neuritis, sensory aphasia, alexia, and agraphia, slight right hemiplegia, and hemianaesthesia.
There was a remarkable recovery from all symptoms as the result of the operation, but two months afterwards
patient died of pneumonia. The tumour proved to be an infiltrating glioma. The plasma filling a malignant
cyst is difficult to drain, as it coagulates on cooling.
2 A
354 SOME POINTS IN THE SURGERY
Tuberculosis of Cerebrum.
Tuberculosis of the brain, whether in the
form of miliary tuberculosis, or in the form of a
localised tumour or tumours, has its origin in
the meninges. A tubercular tumour, even when
found deeply imbedded in the brain substance,
has commenced to develop in the sheaths of the
vessels that penetrate the brain substance from
the pia mater. A solitary tubercular mass is
simply a conglomeration of miliary tubercles
with degeneration of the intervening tissue. It
may reach the dimensions of an ^g^- When
several such localised masses are present, only
one may cause the symptoms, the others being
^'latent"; this is especially true in children,
who are more frequently the subjects of such
tumours than adults. The difficulties of suc-
cessful surgical intervention and the possible
disappointments are obvious.
I will relate two recent cases of my own
affecting the cerebrum, the one successful and
the other fatal : —
I. A widow, aged fifty-six years, under die care of
Dr. Ferrier and Dr. Purves Stewart. Seen July 6,
1905. Some three months previously, when feeling
OF TUMOUR OF THE BRAIN 255
otherwise quite well, she felt a sudden sensation of
weakness in the left hand. This soon passed off, but
similar attacks continued to occur, at first two or three
times a day only, but soon increasing in frequency,
until twenty or thirty occurred in the course of a single
day. After a while clonic jerks of the whole upper
limb from fingers to shoulder, apparently simultaneous
at all joints, were added to the feeling of weakness.
During the attacks there was no loss of consciousness.
No twitchings of face or lower limb were observed.
Fig. igo. — Diagram of site of tuberculous tumour behind the central fissure.
(Dr. Ferrier's case.)
During the last fortnight the attacks have again
diminished in frequency to two or three a day. The
left hand has, throughout, felt perfectly well in the
intervals between attacks, but the left leg has become
weak and drags a little in walking. There has been
no headache nor vomiting, and no affection of sight.
When seen there was slight weakness of the left
lower limb at all joints, with some exaltation of the
deep reflexes on the same side. There was no affection
of deep or superficial sensation. The optic discs were
normal. There was no cranial tenderness. Fluid
356 SOME POINTS IN THE SURGERY
remov^ed by lumbar puncture showed moderate lympho-
cytosis. The intra-dural pressure was not excessive.
The weakness of the left lower limb increased, the
ankle and toes becoming completely paralysed. The
left upper limb became distinctly weak, but all move-
ments were possible. Twitchings of left arm and
hand were observed at intervals, and slight twitchings
of left toes sometimes accompanying, sometimes pre-
ceding, and sometimes following those of the left hand.
Sensation, both deep and superficial, remained normal,
as did also the optic discs, the pupils, and the cranial
nerves. Supinator jerks increased, left greater than
right, left knee-jerk much greater than right, ankle
clonus present on left side. Left plantar reflex extensor,
right flexor.
On July 24 I removed bone over the upper part of
the right Rolandic area ; the skull was abnormally
thick.
July 27. — Yesterday slight twitching at left shoulder
and in left lower limb, commencing at hip and spreading
to toes. No increase in paralysis of limbs. Left face
moves less than right on smiling. July 28. — Yesterday
at 2.45 P.M. felt a sensation of weakness in the
epigastrium, followed by twitchings in left lower limb
from the thigh to the foot, simultaneously in the
toes, duration i\ minutes. At 7.10 p.m. twitch-
ings in left lower limb preceded by sensation of
" needles and pins " in hallux. Patient felt the twitch-
ing first on the outer side of the knee, but the
jerking was visible from thigh to foot, gradually in-
creasing in severity. The foot did not change its
position as a whole. With each spasm the hallux was
sharply drawn up, the second toe slightly, the remaining
toes being unaffected. 10,45 p.m. — Three attacks of
OF TUMOUR OF THE BRAIN 357
twitching, beginning in the left shoulder and spread-
ing down the arm, also from the left hip to the ankle.
No movements of toes. 3.15 a.m. — Jerking from left
shoulder down to fingers ; then from left thigh to foot.
Hallux drawn up at each movement and foot inverted.
9 A.M. — Can feebly move left upper limb at all
joints. Flaccid palsy of left lower limb, total at toes
and ankle, severe, but not absolute at knee and hip.
Cutaneous sensibiHty normal. Can localise light
touches everywhere. Sense of position on passive
movements lost at left toes and ankle, normal at knee
and hip ; also lost at left fingers and wrist ; impaired
at left elbow and shoulder. Reflexes as before.
On July 3 1 I reflected a flap of dura and exposed
the upper part of the Rolandic area. The dura was
hard and tough, and a small calcareous plate about as
large as a sixpence adhered to its deep surface and to
the pia mater. The corresponding portion of the
cortex (post-central gyrus) was of a deeper shade of
grey than the remaining healthy cortex. By means of
a silver teaspoon this more deeply grey part was ex-
plored, and a yellow caseous nodule about the size of a
thimble was dug out from the subjacent white matter ;
it had a narrow stalk connecting it with the thickened
and adherent meninges. The whole area of disease
was within one inch of the middle line.
August 1st. — During last night six or seven attacks
of twitchings of left upper limb from elbow to hand.
On one or two of these occasions the left face also
twitched, and once the left foot. To-day, total flaccid
paralysis of the left upper and lower limbs at all joints.
Left face very slightly weaker than right. Tongue
straight. No hemianopia. Anaesthesia to touch and
pain of left upper and lower limbs, absolute in hand
358 SOME POINTS IN THE SURGERY
and foot, decreasing in intensity towards proximal
segments of limbs. No hemianassthesia of trunk,
lo P.M. — Four or five attacks of twitching of left
hand during the day. In one of these the march was
upwards from fingers to shoulder, and then to head and
left face. August 2nd. — Two attacks of twitching
during last night, both in the face. The second one
also in the left hand. August yd. — Three slight
attacks of twitching of face in last twenty-four hours,
and one attack of " pins and needles " in left hand.
August 4//^.— Two attacks of " pins and needles " in
hand, and once slight twitching of hand and left
eyelid. August ^th. — One slight attack last night
in the hand ; one attack this afternoon in left face.
August 6th. — Slight twitching of left thumb and index
at 9 A.M. At 7 P.M. "pins and needles" in the left
foot. August loth. — No more twitchings or tinglings
since last night. All stitches now removed from wound.
Can feel lightest touches everywhere on left side as
acutely as on right. Still total flaccid paralysis of left
upper and lower limbs. September 22nd. — Wound
healed. Total paralysis of left upper limb at all
joints. No movement of trapezius. Sterno-mastoid
normal. Latissimus contracts on coughing. Face
normal. Lower limb has fair movements at hip and
knee ; none at ankle or toes. With support can just
stand and walk, dragging the left leg. No anassthesia
to lightest touches on arm or leg. Can localise sensa-
tions well. Astereognosis of left hand. S.J.'s, K.J.'s,
A.J.'s, left much greater than right. Right patella
clonus, and A.C. Plantars left extensor, right flexor.
Patient gradually improved, and when she left London
had to a considerable extent regained power in the hemi-
plegic limbs, and was able to walk.
OF TUMOUR OF THE BRAIN 359
Re?narks. — The spasm ot the hallux and toes localised
the tumour in the upper part of the Rolandic area,
and the depth from which the disease was removed
explains the increase of the paralysis and anaisthesia
which took place after the operation. There was no
optic neuritis throughout.
II. A man, aged twenty-five years, who had evident
signs of phthisis, and had had syphilis, was admitted to
hospital under Dr. Aldren Turner on June 21, 1905.
In the preceding November he experienced a feeling of
numbness in both hands, which became specially marked
in the right. About Christmas time, one day when he
was lying down quietly, he noticed for the first time
a trembling in the right hand ; after this he had tremors
of the right hand lasting about an hour two or three
times a day, but they have not increased in frequency
or in severitv. \n March 1905 he had, for the first
time, a fit. There was no warning beyond some increase
in the tremor of the hand, which seemed to affect
particularly the ring and the little finger ; the fingers
were drawn up, the arm stiffened, consciousness was
lost, and the patient became convulsed. The right leg
was not affected. Since then he has had several fits,
usually of about three minutes' duration ; after one of
them he found that he had lost the use of his right
little finger. About March he noticed some weakness
of his right arm, but cannot say whether this commenced
before or after the first fit.
Some three weeks before admission the right ankle
became stiff. He has not had much headache, but has
suffered a good deal from giddiness. He has only
vomited when coughing.
On Admission. — Some paresis, with spasm of the right
360 SOME POINTS IN THE SURGERY
hand. Flexion of the elbow is weak, extension fair ;
all movements of wrist weak. The hand goes into the
position of ulnar flexion, the fourth and fifth fingers are
flexed at the proximal phalanges and extended at the
distal, and the hand seems drawn towards the ulnar
side by clonic spasms which occur three or four times a
day, each lasting about an hour. Left arm and both
lower extremities normal. Temperature 100°, pulse 100.
Slight optic neuritis, rather more marked on left side.
No limitation of visual fields. No affection of other
cranial nerves. Sensation normal. Reflexes normal.
I operated on July 20 and 26. Skull dense and thick.
A parallelogram of bone was cut away, and a dural flap
made so as to expose the left Rolandic area from the
longitudinal sinus to the Sylvian fissure. The cortex
bulged slightly. Shock was so severe that the wound
was closed without further exploration. The patient
died six days later. The temperature rose to 108°
shortly before death.
Autopsy. — Attached to the under surface of the dura
near the falx there was a firm mass about the size of a
cherry, which had depressed the cortex of the left para-
central lobule at its upper margin where the fissure of
Rolando commences. The pia-arachnoid was thickened
and milky, especially in the inter-peduncular space. The
convolutions of the left Rolandic area were flattened, and
beneath them a firm mass could be felt. Another mass
could be felt beneath the caudal end of the second frontal
convolution. The right hemisphere was apparently
normal.
After hardening, besides the meningeal tumour above
mentioned, there were found on section three other
tumours ; one about i^ cm. broad, and extending to a
depth of 2^ cm., which apparently originated in the
OF TUMOUR OF THE BRAIN 361
Rolandic fissure and extended beneath the cortex
equally in front and behind it. It was hard and
circumscribed, and involved the pia. The two
others, both spherical, about ;| cm. in diameter, were
superficially placed, the one in the posterior part of
the right first frontal convolution, and the other in the
posterior end of the left second frontal convolution.
Both were hard and circumscribed, resembled the cortex
in colour, and adhered to the dura. Forebrain was cut
in coronal sections, but no other tumours could be
found, nor any evidence of disease. (Left arm centre
minutely examined.) Membranes thickened and
gelatinous (tubercle bacilli found in films) at the
base ot the pons and ventral surface of the cere-
bellum.
A small firm tumour, the size of a pea, was found in
the substance of the posterior part of the ventral side
of the left lobe of the cerebellum, quite superficial and
attached to the pia. Nothing else in the pons, cerebellum,
or midbrain. Spinal Cord. — ^Pia-arachnoid thickened
and gelatinous, especially in the dorsal and lumbar
regions. No tumour. Microscopically. — All the tumours
are tubercular growths completely caseous, surrounded
by a narrow ring of cellular tissue, in which tubercle
bacilli were found. Brain tissue in which the tumours
lay was not much disturbed, being only displaced. There
was no degeneration in the spinal cord.
Remarks. — The case illustrates the condition of
multiple tubercular masses involving several parts of
the brain with focal symptoms apparently indicating
localisation of the disease in one cortical centre, viz.
that for the right arm. It also shows how little such
patients are able to bear severe operative measures when
the lungs are also affected.
362 SOME POINTS IN THE SURGERY
It has been already pointed out that localising
signs to be of much value must arise early in
cerebral tumour. This fact has been specially
emphasised by James Collier in his instructive
paper on the false interpretation of the signs of
intra- cranial tumour. Such signs led to an
erroneous interpretation in 20 out of 161 cases
analysed by him. The above case is an illustra-
tion of such error in localisation. Symptoms
which may lead to a wrong diagnosis are fits,
cranial nerve paralyses, and certain so-called
" cerebellar signs." The pathological condi-
tions which may cause error in localising a
tumour include hydrocephalus, spreading oedema
around the neoplasm, vascular lesions co-existing
with the neoplasm, and metastases from the
primary growth.
OF TUMOUR OF THE BRAIN 363
Tumours of Large Size.
Tumours, whether arising in the meninges or
in the brain substance itself, may attain a large
size, involving in their growth more than one
anatomical region. As sarcomata in other parts
of the body grow to a great size, so we meet
with sarcomata of the brain which have become
diffused throughout the hemicerebrum, the
brain substance being almost entirely replaced
by tumour tissue. Some of these cases have
been described as glio- sarcoma ; but this is
somewhat begging the question of their nature,
though it is by no means always easy to say
definitely whether a given microscopical speci-
men represents a glioma or a sarcoma.
As germane to this point some observations
of Max Borst are of interest : — A glioma of the
brain being of epiblastic origin, while sarcoma
is of mesoblastic origin, a tumour which is both
a glioma and a sarcoma must have originated
in two different tissues. Such a combination is
conceivable, but he has not observed it. A
glioma but rarely invades the meninges at all^
and never oversteps the limits of the pia, and
never gives rise to metastases in other organs ;
364 SOME POINTS IN THE SURGERY
while sarcoma, if not growing from the meninges,
often invades them. The arrangement of tumour
cells around the blood-vessels is characteristic of
sarcoma. Some gliomata arising deeply in the
brain exhibit epithelial inclusions, and may have
arisen from the ependyma in diverticula of the
original central nervous cavity.
A pure glioma does not form a solid tumour
obviously distinct from the brain substance of
such a size as does a sarcoma, and even when
extensively diffused through the brain tissue
does not alter the shape and appearance of the
hemisphere to the same extent. Cystic de-
generation is a common change in large
gliomata. A very large tumour must have been
of slow growth, since a rapidly growing tumour
causes urgent pressure symptoms and speedy
death. The slowly growing tumour in its early
stages may give rise to no localising symptoms,
while in its later stages the presence of signs
indicating a lesion of the deeper regions of the
brain often becomes manifest, and produces a
curious reluctance on the part of the physician
to advise operation. The syndrome symptoms
may be absent in a slowly growing tumour.
Duret observes : " In some cases the appearance
of the syndrome symptoms is delayed for several
years — five or even ten years — in benign or
OF TUMOUR OF THE BRAIN 365
slowly growing tumours. It should be re-
membered that the syndrome is really an
epiphenomenon in the evolution of brain
neoplasms, brought about by collateral lesions,
particularly by increase of intra-cranial tension,
which may be absent. . . . The diagnosis may
be made in those cases of tumour of brain in
which intellectual and psychic disturbances are
the chief phenomena, by remembering that
madness when accompanied by severe headache
or localised paralytic phenomena ought to make
us think of a gross lesion of the brain, and more
particularly of a tumour." The syndrome
symptoms are commonly wanting in tumours of
the corpus callosum, of the pons, and of the
medulla, and appear later in tumours of the
motor region than in tumours of other regions
of the cortex."
The symptoms so well described by Duret
do not necessarily indicate the presence of a
large tumour, but they point to the desirability
of an exploratory operation which may end in
the removal of the tumour or the relief of
symptoms by decompression.
The following are a few illustrative cases of
large tumours : many others might be cited : —
366 SOME POINTS IN THE SURGERY
/. Bramann s Case.
A man, aged twenty-nine years, began in April 1891
to suffer from right-sided headache and from vertigo.
The attacks were repeated at varying intervals and with
varying intensity. In the summer of that year he had
a blow on the right side of the head. In October,
while sitting smoking a cigar, the cigar dropped out of
his left hand and his face became distorted. Since then
there has been gradually increasing weakness of the left
hand. He had two further fits during the next eight
weeks. In November 1891 the headache increased and
the sight of the right eye began to fail rapidly, and
some impairment of the power of attention was noticed.
He also had double vision, but this was temporary. In
March 1892 the sight of the right eye was reduced to
perception of light, and failure of sight of left eye
became noticeable ; by the end of April he could only
count fingers. There was slight vertigo, but no
vomiting. On April 21, 1892, he was admitted to
Bramann's clinic. The head was bowed forwards and
inclined slightly towards the left. Pupils sluggish.
Double optic neuritis most marked on right side.
Sight very defective, and fields contracted. Left
facial palsy ; decided paresis of left arm, especially of
fingers and hand ; there was slight paresis of left leg,
but right leg seemed weaker than normal. Reflexes
exaggerated on both sides, especially on the left.
There was oedema and tenderness of scalp in right
fronto-parietal region where the patient localised his
headache. On May i he had a fit with twitchings of
left side of face, and a feeling of numbness in left hand
and leg.
May 3. — Operation in right fronto-parietal region.
OF TUMOUR OF THE BRAIN 367
Bone very thin. About 8 cm. sq. of dura exposed.
Dura very vascular. Hard tumour, evidently clearly
marked off from brain, felt through dura ; more bone cut
away until limits of tumour felt, then dura incised about
2 cm. beyond growth. All vessels tied before division
as operation proceeded. The tumour measured 8 cm.
from before backwards, and 7 cm. from above down-
wards. It was enucleated step by step, the part over
the ventricle being left to the last. The operator
thought his finger went into the ventricle, but con-
sidered it imprudent to verify this. After the tumour
was removed almost the whole of the longitudinal
fissure could be seen, and most of the ethmoid. The
patient made a good recovery. The growth weighed
280 grammes (9.875 oz.), and was a sarcoma with both
spindle and round cells, and enclosed in a capsule of
connective tissue.
//. Ballet and Delilles Case.
Male, aged fourteen years. Admitted September 20,
J 900.
Fir;. 191. — Large sarcoma of cerebral meninges. (Ballet anil Delille.)
368 SOME POINTS IN THE SURGERY
Four years previously had epileptic fits, which
occurred at intervals during two years, and then ceased
under potassium bromide, leaving, however, a slight
right facial paresis. Nine months before admission he
began to have vomiting and trophic lesions (alopecia)
of scalp. When admitted he had been drowsy and
dull for a month. There was alopecia of the left
temporo-parietal region with oedema of the scalp. The
left eye appeared deeper in the orbit than the right,
and squinted downwards. There was right facial palsy
and paresis of right arm. The patient complained of
headache, and had optic neuritis. Fasces passed in-
voluntarily. He could stand, but only with difficulty.
No difference in power of legs. He had several fits,
and died four months after admission.
Autopsy. — Old tubercle in both apices. A very large
tumour involved the left frontal lobe. When the brain
was removed the tumour was seen to project like the
head of a mushroom, 5 cm. above the surface of the
hemispheres. It measured 12 by 10 by 15 cm., and
was attached by a comparatively small pedicle, the
section of which measured 3 by i\ cm. The con-
volutions beneath the tumour were flattened. The
posterior extremity of the left third frontal convolution
was involved, but there was no aphasia. The growth
was a sarcoma.
///. Dercum and Keens Case. Brief Abstract of
Symptoms, May to November 1902.
H. W., aged twenty-six years. Dull headache.
Irritability of temper for previous four months. Slight
loss of control of movements of right hand. Several
attacks of vomiting. Bilateral optic neuritis, most
advanced on left side. Paralysis of right external
OF TUMOUR OF THE BRAIN 369
rectus, slight weakness of right side ot face. Astereo-
gnosis of right foot. Achilles clonus right side. Slight
diminution of sensibility in right lower limb to pain,
touch, and temperature. Tenderness in left post-
parietal region sometimes present, but not always
demonstrable. Later some numbness of left side of
face.
November 1902. — Left temporal region explored ;
result negative.
March 1903. — Hemiplegia and hemianaesthesia of
right side of gradual onset. The hemianaesthesia was
most decided in the distal portion of the extremities.
Right homonymous hemianopsia, without Wernicke's
sign. No word - deafness, but characteristic word-
bhndness. Partial anosmia. Complete astereognosis.
■ Operation in three stages in left parietal region.
The tumour, an encapsulated spindle-celled sarcoma,
weighing 264 grammes (9.3 oz.) was removed. The
parenchymatous haemorrhage from the bone was difficult
to arrest — a condition often found in bone infiltrated
by sarcoma. The patient died soon after the operation.
Remarks. — The interest of this case lies in the
presence of an enormous tumour with absence of
striking localising symptoms until late in the case.
" In reviewing the symptoms we are impressed with
the fact of the insignificant value of paralysis of one
abducens or of trifacial hypaesthesia. The case does
demonstrate the localising value of astereognosis and
slight muscular inco-ordination."
IV. Mills and Pfahlers Case.
A woman, aged thirty-two years, was admitted to
hospital in October 1901. Some months before she
began to lose power in the right leg, and the right arm
2 B
370 SOME POINTS IN THE SURGERY
soon after became affected. She suffered from severe
headache.
Symptoms on and after Admission. — Right hemiplegia
Fig. 192.
Fig. 193.
Fig. 192. — Horizontal section of left cerebral hemisphere, showing large fibro-
sarcomatous tumour of left parietal region. The tumour was chiefly subcortical.
(Mills and Pfahler.)
Fig. 193. — Radiogram of this tumour of the brain in the living patient. Note
the dark shadow in the lower parietal region. (Pfahler.)
most marked in arm. Sensation to touch and pain lost
in right upper extremity, impaired in right lower
extremity. Muscular sense and stereognostic percep-
OF TUMOUR OF THE BRAIN 371
tion also impaired. The Joss of all forms of sensation
became more decided as time went on. Marked
bilateral optic neuritis. Right homonymous hemi-
anopsia. All deep reflexes exaggerated on right side.
Attacks of agonising headache. Mental state well
preserved.
Diagnosis. — Large dense subcortical tumour. A
distinct shadow was obtained on examination with the
Rontgen rays, and the diagnosis was fully confirmed
by operation and necropsy.
The severe pain in head made operation imperative,
the diagnosis being large subcortical tumour in parietal
region.
Operation by Drs. Hearn and da Costa.
The parietal region and ascending frontal convolution
were exposed. A nodulated mass 1.8 inches in diameter
coming through the cortex was removed. Death
occurred two hours later.
Autopsy. — Tumour removed had been broken off
from a large subcortical mass. The tumour reached
the internal capsule and thalamus, but did not invade
them.
Dr. Pfahler ably comments on the method to be
employed to obtain Rontgen-ray photographs of brain
tumours.
Remarks. — The tumour was large and for the most
part subcortical. It reached the thalamus and occupied
most of the parietal lobe. It was a fibro-sarcoma.
The tumour was localised by clinical study and by the
Rontgen rays. This is the second case in which the
rays localised a brain tumour ; the first case was
published by Church {^Amer. Journal of the Med. Sci.)
in February 1899.
372 SOME POINTS IN THE SURGERY
Conclusion.
I have now only to express the hope that in
this lecture I have been able to show that the
victims of tumour of the brain have, in surgical
intervention, a means of relief, and sometimes of
cure.
Starr quotes with approval the dictum of
Keen, that " these operations are not to be rashly
undertaken by the novice in Surgery " ; but it
may well be asked what operation should be
rashly undertaken by the novice or by the
master ?
Cases of brain disease requiring surgical relief
are numerous and widely distributed, but those
who operate on these cases are few and far
between. Not so long ago the same was true
of acute abdominal diseases, but now the surgery
of acute abdominal disease is successfully prac-
tised by the great body of surgeons. Until this
stage in the history of brain tumours has been
reached many remediable cases must go un-
relieved. Up to the present, those of us who
have worked in this field have been passing
through a period of criticism, of opposition not
OF TUMOUR OF THE BRAIN 373
always friendly, of many disasters, and of some
great achievements. Indeed, the history of
operations for brain tumour, so far, may be
compared to that of the early years of ovario-
tomy. Of those v^ho have contributed to
the slow but certain progress of this depart-
ment of Medicine and Surgery some are known,
but many are unknown to fame. Though
in this, as in every other branch of science,
each stage in the advance of knowledge
is associated more particularly with one or
several great names which are interwoven with
its history, we ought never to forget what is
due to those of less renown — the most obscure
practitioner who has accurately observed and
recorded an important fact, he also has added
his stone to the building. And to such an one
I would recall the words spoken on a memorable
occasion by the late Sir James Paget, " No good
work is ever wholly lost."
I may fairly claim that, in the great achieve-
ments of the past, the strenuous and scientific
labours of my colleagues at the National Hospital
have had a large share.
As to the future we cannot —
" look into the seeds of time,
And say which grain will grow and which will not,'"
374 SOME POINTS IN THE SURGERY
but I am convinced that the dawn of a happier
day for these terrible cases has come : —
" And not by Eastern windows only,
When daylight comes, comes in the light :
In front the Sun cUmbs slow — how slowly ;
But Westward look, the land is bright."
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OF TUMOUR OF THE BRAIN 375
Braun, H. Verhand. d. Deut. Gesell. f. Chir. 1892, pp. 439
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1897, P- 73-
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783 ^/ seq., and pp. 848 et seq.
Cestan and Lejeune. Revue de Neurologic, 1901, p. 840.
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Chipault, a. Chirurgie operatoire du Systeme Nerveux, vols. i.
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Clough. Say not the Struggle nought availeth.
Collier, James. Brain, vol. xxvi.
CoLMAN and Ballance. Clinical Society's Transactions, vol. xxix.
Cruveilhier, Jean. Anatomic pathologique du Corps Humain.
Cunningham, Prof. D. J. Right-handedness and Left-brainedness.
Huxley Lecture, 1902.
CusHiNG, Harvey. The Establishment of Cerebral Hernia as a
Decompressive Measure for Inaccessible Brain Tumours.
"Surgery, Gynaecology, and Obstetrics," October 1905.
Dana, Charles. New York Medical Journal, 1905, p. 270.
Dawkins, Prof. Boyd. Quoted from Cunningham.
Dercum and Keen. Journal of Nervous and Mental Disease, Dec.
1903.
Dudley, W. Brain, vol. xi. p. 503.
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Durante, Francesco. Quoted from Roncali.
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Frazier, Charles. Remarks upon the Surgical Aspects of Tumour
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" Univ. of Penn. Med. Bull." 1906.
Grunbaum and Sherrington. Proceedings of the Royal Society,
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Guthrie, G. J. On Injuries ot the Head affecting the Brain.
376 SOME POINTS IN THE SURGERY
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OF TUMOUR OF THE BRAIN ijj
Mills and Pfahler. Philadelphia Medical Journal, Feb. 1902.
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Two sets of valuable papers which have been of much use to me,
and which I recommend to others, have been recently contributed
by the Philadelphia School. Those relating to the cerebellum
appeared in the New York Medical Journal in 1905 ; and those
relating to the cerebrum in the University of Pennsylvania Medical
Bulletin in 1906. I append a list of these papers : —
378 SOME POINTS IN THE SURGERY
The Diagnosis of Tumours of the Cerebellum and the Cerebello-
pontile Angle, especially with reference to their Surgical
Removal. By Charles K. Mills.
Remarks upon the Surgical Aspects of Tumours of the Cerebellum.
By Charles H. Frazier.
The Pathology of Cerebellar Tumours. By T. H. Weisenburg.
The Diagnosis of Cerebellar Tumours. By Joseph Fraenkel.
The Ocular Symptoms of Cerebellar Tumour. By G. E. de
Schweinitz.
The Functions of the Cerebellum. By Edward Lodholz.
Report of a Case of Cyst of the Cerebellum. By John M. Swan.
The Cerebellar Seizure (Cerebellar Fits) ; a Syndrome Character-
istic of Cerebellar Tumours. By Charles L. Dana.
On the Diagnosis of Operable Tumours of the Cerebrum. By
Charles K. Mills.
The Ocular Symptoms of Tumours of the Cerebrum. By G. E.
de Schweinitz.
The Surgical Aspects of Tumours of the Cerebrum. By Chas. H.
Frazier.
To these maybe added a paper by Dr. P. C. Knapp, of Boston, "On
the Results of Operation for the Removal of Cerebral Tumours,"
read at a meeting of the American Neurological Association held at
Philadelphia in June 1905.
OF TUMOUR OF THE BRAIN 379
Additional Cases of interest that occurred while
this book was in the press^ two of which illus-
trate the application oj X-ray photography in
the diagnosis of Tumour of the Brain.
I. Large Tumour of Frontal Lobe without
Optic Neuritis (Figs. 194-198),
Man aged 52 years. Under the care of Drs. Evans
and Zieman. He was a total abstainer, but rather
inclined to free indulgence in eating. He had had
no previous illness, and there was no history of syphilis.
He had been married twenty-five years ; his wife had
had two children, both healthy.
On March 29 he had a fit in his office, and was
brought home in a cab ; after the fit he vomited. He
resumed his business the next day. On April 22 he
had another fit, after which he also vomited. He went
back to his work the next day (April 23), but had three
fits the course of which was not observed. After this
he rested for two weeks before resuming business. A
^Q-^N months later he went to Switzerland for three weeks
with his family. His speech had become slower than
normal, he would often miss his train, and became
excited and emotional. Li Switzerland his family had
much trouble and anxiety about him. He returned
home on August 8, and on that day had a fit. About
this time he became very careless about his dress, and
for a time had incontinence of urine. On August 16,
weakness of left hand was observed, and on August 20,
the left side of the face and the left leg were similarly
affected. Since the commencement of the illness he had
had severe headaches at intervals.
He was seen in September by Dr. Risien Russell, and
380 SOME POINTS IN THE SURGERY
a few days later, on the 14th, by me. He then had left
hemiplegia, the loss of power behig most profound in
the arm, with very slight hemi-anassthesia, amounting
to only slight dulness of sensation to light touches.
Localisation was good. Ankle clonus was obtained on
the left side. There was no optic neuritis. Mentally
he was dull and slow. There had been no incontinence
of urine since August.
On September 15 I removed bone over the right
fronto-parietal region, and on the 24th opened the dura.
The middle and upper part of the frontal lobe bulged,
a large subcortical tumour was removed which occupied
the first and second frontal convolutions, and the whole
of the white matter beneath. It weighed over 2 oz.
The patient stood the operation remarkably well, the
blood pressure only fell from 125 to 105 mm. of Hg.
For a few days all went well, but the patient died on
October i, from acute spreading lobar pneumonia of
the right lung, possibly of influenzal origin. The
local operation conditions were normal — cerebro-spinal
fluid was draining freely.
Dr. Zieman took X-ray photographs of the
patient's head which demonstrated the position of the
tumour. I could not make out distinctly the tumour
from a study of the negatives, but on the bromide
prints the outline of the tumour could clearly be seen by
oblique illumination, indeed much more clearly than is
expressed in the reproductions (Figs. 197 and 198). I
ought to add that the skull was remarkably thin.
Dr. Zieman contributes the following facts : — The
plates were imperial special rapids lo^'x 'i". The dis-
tance was 1 8 inches. The exposure in the side view was
four minutes, and in the top view five minutes. The tube
was very soft, having been lying by for eighteen months.
OF TUMOUR OF THE BRAIN 381
Fig. 194. — From a photograph. The dotted line shows the area of bone removed.
R, Site of furrow of Rolando.
382 SOME POINTS IN THE SURGERY
Fig. 195. — Sketch to show area of brain exf
R, Furrow of Rolando ; F^, F^, F^, frontal convolutions.
OF TUMOUR OF THE BRAIN 383
Fig. 196. — Microscopic section of frontal tumour.
The tumour is a glioma with giant cells.
384 SOME POINTS IN THE SURGERY
i
i
Fig. 197. — Radiogram by Dr. Zieman of frontal lobe tumour. (Side viev
OF TUMOUR OF THE BRAIN 385
Fig. 198. — Radiogram by Dr. Zieman of frontal lobe tumour.
(View from above and in front.)
2 C
386 SOME POINTS IN THE SURGERY
2. Tumour of Base of Skull with Meningitis
serosa, mistaken for intradural tumour
of the right cerebellar fossa (fig. i99).
On October 4th I was asked by Drs. Harold and
Risien Russell to see a man aged 40 years. For about
eight weeks he had had a vague feeling of general ill
health, but without definite symptoms, until three weeks
before the date of my visit. He then had pain in the
right ear ; this subsided after a day or two, but left him
deaf in that ear and with weakness of the right side of
the face. The right-sided deafness and facial palsy
became absolute. He was semi-stuporous when I saw
him, and for two or three days it had been observed
that at times he was unable to name objects correctly
and that he occasionally used wrong words. He had not
had headache, vomiting, giddiness, or inco-ordination
of limbs. The reflexes were brisker on the right side
than on the left. The right upper limb was distinctly
weak, and the grasp of the right hand feeble. Pulse 100 ;
temperature 100°. He could be roused, and sometimes
answered questions correctly. There was no decided
optic neuritis, but it was thought that the retinal veins
were fuller than they had been a few days previously.
He had certainly had syphilis. The diagnosis was
syphiloma or other tumour involving the anterior part
of the right cerebellar hemisphere.
The next day the dura in the right cerebellar fossa
was exposed. In working forwards towards the
descending portion of the sigmoid sinus I encountered
a mass of granuloma or new growth lying between the
outer surface of the dura and the posterior aspect of the
petrous and mastoid bones. In the hope that this was
1
OF TUMOUR OF THE BRAIN 387
a syphiloma the wound was closed. The dura was not
abnormally tense. Next morning he was much worse,
insensible, and with a slow pulse. The flap was hurriedly
thrown down, and the dura, which had become very
tense, opened. On insinuating the finger between the
posterior surface of the petrous and the cerebellum
much cerebro-spinal fluid escaped. There was no
growth inside the dura. Patient did not rally, and died
in twelve hours.
^
y^'
Fig. 199. — Microscopical section of growth found between dura of posterior fossa
and temporal bone.
The growth was a sarcoma growing either from the outer surface of the dura or
from the temporal bone. The upper portion of the drawing shows a portion of the
mastoid bone which was superficially invaded by the tumour.
A radiogram of the head (side view) was taken by
Dr. Zieman, but as the patient became rapidly worse
was not seen before the operation. As in the last case
the bromide print showed the site of the tumour ; a
388 SOME POINTS IN THE SURGERY
crescentic dark area about a quarter of an inch in width
at its centre was visible by obHque illumination, marking
the site of the tumour which separated the dura from
the posterior surface of the petrous. An attempt was
made to reproduce this efFect, but was unsuccessful.
Figs. 200 and 201. — Microscopical Appearances of
the Case of Frontal Lobe Tumour described under
Figs. 175-182.
Fig. 200. — Portion of the tumour near the base of one of the greyish processes,
which extended between the brain and the frontal bone (x 175).
Note the tendency to concentric arrangement of the cells so as to form whorls.
OF TUMOUR OF THE BRAIN 389
mmcm
Fig. 201. — Section through a villous process showing the longitudinal arrange-
ment of the vessels 5 see description, p. 324. (x 22.)
390 SOME POINTS IN THE SURGERY
4. Figs. 202-206 illustrate a tumour of the outer sur-
face of the dura mater kindly sent to me by Dr. Thomson
of Scranton in Pennsylvania. It reached me on 14th
December 1906, when this work was already in print,
but it is of such interest that, although I have no
clinical history of the case, I decided to add it at the
last moment.
The growth weighed (in the preserved state) 907
grammes, almost equalling the weight of the brain
(in the preserved state), which was 915 grammes.
The growth measured 17 cm. from before backwards,
9.5 cm. from side to side, and to cm. from above
downwards. It lay obliquely across the upper surface
of the dura of the vertex. Its long axis was directed
from in front and the left, obliquely backwards and to
the right, and crossed the superior longitudinal sinus a
little behind its middle at an angle of about 30.
The growth was intimately adherent to the dura
over a considerable area, and had perforated the
cranium and scalp. It protruded through the skin
as an oval fungating mass, measuring 9 by 8.4
centimetres.
Where not adherent to dura or scalp the limits of
the growth were well defined, and its surface was in
places smooth, in others nodular.
The brain had evidently suffered great compression,
especially the posterior two-thirds of the left hemisphere,
and was much distorted in shape. It was not infiltrated
with the growth, the inner surface of the dura was
intact. Histologically the growth was a spindle-celled
fibro-sarcoma. The bulk of the growth was made up
of long fusiform cells arranged in bundles mostly
parallel to the long axis of the vessels. In places the
cells appeared to be of different sizes and shapes, and to
OF TUMOUR OF THE BRAIN 391
be arranged in whorls, but this was due to bundles of
long cells being cut obliquely.
Where adherent to the outer surface of the dura
there was no sharp line of demarcation between growth
and dura, but the long fusiform cells of the growth
seemed to pass into the fibres of the dura ; the dura
itself was nowhere completely destroyed, but groups of
sarcoma cells could in places be seen in its outer part.
Near the dura were numerous pigment granules appar-
ently derived from the blood.
In sections, including a portion of skin, the limit
between skin and growth was in some places well
defined, in others the growth had extended into and
blended with the deep layer of the skin. Outlying
groups of sarcoma cells could be seen in the thickness
of the skin, and here and there groups of sarcoma cells
blocked the vessels. Near the skin the bundles of long
spindle cells were less compact and less regularly arranged
than in the part of the growth near the dura. Near the
skin, bundles of well-developed fibrous tissue were present.
Where the fibrous bundles and spindle cells were cut
transversely or obliquely the appearance resembled that
of alveolar sarcoma.
The growth was only moderately vascular, the walls
of the vessels were ill-developed.
An instance taken from Auvert's work of sarcoma
of the outer aspect of the dura mater attaining great
dimensions, and in some respects resembling Dr.
Thomson's specimen, is described on pages 215 and
216, and figured on page 224.
392 SOME POINTS IN THE SURGERY
Fig. 202. — Photograph by Dr. C. E. Thomson of the tumour and the brain
placed side by side to show their relative size.
OF TUMOUR OF THE BRAIN 393
Fig. 203. — Photograph of the tumour and dura taken from above and somewhat
from the right, showing the position of the tumour lying obliquely across the upper
surface of the dura.
A, A, Line of longitudinal sinus ; S, S, line of section shown in next figure.
394 SOME POINTS IN THE SURGERY
Fig. 204. — Photograph of section of tumour made in the direction indicated by
the line S, S, in the preceding figure. The view is of the posterior half of the section
from in front.
V, Superior longitudinal sinus seen in section ; R, dura of right hemisphere ; L,
cut edge of dura of left hemisphere ; F, falx cerebri ; T, tentorium cerebelli ; E, E,
edge of ulcerated opening in scalp.
Note the ulceration of the tumour extends deeply, almost reaching the dura, and
also that the inner aspect of the ikira is intact.
OF TUMOUR OF THE BRAIN 395
*^'«SAfo„\-«'
n
Fig. 205. — Microscopic section of the tumour where adherent to dura. ( x 45.)
T, Tumour ; D, dura.
Fig. 206. — Part of the section
shown in the preceding figure.
(x 150.)
T, Tumour invading or growing
from the outer layers of dura,
which are separated by the tumour
cells ; D, inner layers of dura
unaffected by the growth.
D
INDEX
Abscess of Brain —
Clinical evolution of, 125-126 ; sub-
acute, 126-128 J with severe general
infection, 128 ; with latency of
symptoms, 128-129 j simulating
brain tumour, i 30 ; remittent type,
130
Cortical functions, effect on, 98
Deep, point of attachment to dura,
.143
Diagnosis, 125 et seq. ; ot brain abscess
with complications, 133-1345 dif-
ferential diagnosis, 136-138
Direct infection, 92 et seq.
Discovery and incision of, 146-150
Diseases associated with, 88
Encapsulation of, 97-100
Gunshot wounds, due to, 99-100
Indirect infection, due to, 96, 99
Infective diseases, complicating, 88-
Instruments, use ot, in operating tor,
148-150
Latency of, 97, 128-129
Lung disease, secondary to, 90-92
Mode of formation of, 94-96
Multiple, 102-106
Operation for, 140-146 j advisability
of early operation, 151 ; post-opera-
tive symptoms, 151-152
Simultaneous development of, in dif-
ferent situations, 132-133
Stalk of, drainage through, 141
Symptoms, 106-107 j of extra-dural
abscess, 107
Treatment of, 139 et seq.
Tuberculous, spontaneous recovery
from, 100-102
Acland, Dr., case of, quoted, 324
Acute specific diseases simulating men-
ingitis, 59, 60
Agraphia, in parietal lobe tumour, 332,
342
332.
Alexia, in parietal lobe tun
342
American yournal of Medical Sciences,
cited, 321, 371
Amnesia, auditory, 238, 332
Amusia, 117, 120-121, 332
Anaesthesia, 56 ; trigeminal, 248
Angeioma of cranial bones, 211, 213-
214
Angio-glioma, 158
Angio-lithic sarcoma, 159
Angio-s^rcoma of brain following punc-
tured fracture of skull, case quoted,
203-205 ; histology of case, 206-
210
Angular gyrus, tumour involving, 248,
249' 232, 343
Aphasia, 36, no, 1x2-119, 342-343
Aphemia, 1 16-117
Apoplexy, lumbar puncture in, 39-40
Apraxia, in lesions of parietal lobe, 333-
336 5 in case of multiple brain
lesions, 343-349
Arachnoid membrane, 185 serous cysts
of, 25-26 ; suppuration of, 43 j in-
flammation of, 50
Archimedes, principle of, in relation to
brain protection by cerebro-spinal
fluid, 14-15
Arterio-sclerosis of brain arteries, 348
Astasia, 245
Astereognosis, 340-342 ; localising value
of, 369
Asthenia, 243-245
Asynergia in cerebellar tumour, 236
Ataxia —
Cerebellar, 236
Frontal, 313-314
Atonia in cerebellar tumour, 239, 244-
245
Attitude in cerebellar tumour, 233
Auditory nerve, tumour of, 267, 268,
27I' 273
397
398 SURGERY OF THE BRAIN
Axivert, cited, 105, 211, 215-216, 224,
264
Babinski's sign, 29, 57
Ballet antl Delille, cases of, quoted, 320,
367-368
Bardesco, cited, 168
Barlow, Sir Thomas and Dr. Lees, cited,
12-14
Bastian, Dr., cited, 35
Batten, quoted, 233
Beadles, C. F., cases of, 167, 218
Bechterew's nucleus, 24
Beevor, Dr., cited, 157, 324, 331
Beevor and Ballance, case of, quoted,
Beevor and Horsley, case of, cited, ijj
Beevor and Jackson, case of, quoted. I2l-
122
Beevor and Lunn, case of, quoted, 202,
276
V. Bergmann, cases of, cited, 101 ;
quoted, 99, 100
Bernard, Dr., case of, quoted, 192-199
Bird of Melbourne, cited, 169-170
Biroula, cited, 27
Blood pressure in cerebral sinuses, 10
Blottche, cited, 90
Borst, Max, cited, 363
Bouilland, cited, 117
Brain —
Abscess of. See Abscess of Brain
Lesion of substance of, simulating
meningitis, 57, 59, 60
Protection of, by cerebro-spinal fluid,
14-15
Resistance of cortex to bacterial
attacks, 94
Tumour of. See Tumour of Brain
Weight of, supported by hydrostatic
pressure, 14-16
Bramann, case of, quoted, 366-367
Braun of Konigsberg, case of, cited, 218-
220
Breast, carcinoma of skull secondary to
that of, 2 1 1
Bright, Richard, cited, 26, 27, 28, 105
Brissaud and De Massary, case of, quoted,
317-318
Brissaud and Souques, ated, 115, 118,
129
Bristowe, Dr., cases of, cited, 89, 130-
132
Broadbent and Charcot, cited, 1 1 1
Broca, M., cited, 263
Bruce, quoted, 237
Bruns, cited, 313-314 j case of, quoted,
336-338
Burrows, cited, 17
Calcarine fissure, lesions of, 297, 298 ;
bilateral, 298-299
Carcinoma —
Centrum ovale, in, 161-162
Cranium and meninges, of, 2 1 1
Secondary, in skull, 162
Carotid arteries, ligature of, in congenital
hydrocephalus, 80-81
Carswell, cited, 105
Cayley, case of, quoted, 91
Centrum ovale —
Carcinomatous deposit, secondary in,
161-162
Cystic angio-sarcoma of, 323
Sub-cortical sarcoma in, 352
Cephalhydrocele, 19 et seq., 33
Cerebellum —
Abscess in, 103-105, 127, 143 ; mul-
tiple, 103
Cholesteatoma vera of, 160
Cysts, simple, of right hemisphere,
cases quoted, 164, 165
Functions of, 240-243
Gumma of left hemisphere, removal
of, 168
Sarcoma of, following injury, case
quoted, 202
Spreading suppuration in, 100
Tumour of —
Cases quoted, 249-263
Diagnostic symptoms, 230 et seq. ;
diagnosis from occipital tumour
with cerebellar signs, 302
Frontal ataxia distinguished from
that of, 3 1 4
Operations for, 157 ; decompres-
sive, 172
Cerebellar fossa, tumour of, 192-199
hemisphere, removal of, 243-247 .
superior peduncles, 242
Cerebello-pontine tumours, 264, 272
Cerebral circulation, influence of atmo-
spheric pressure on, 17-18
hernia for inaccessible brain tum-
ours, 171-172
irritation, lumbar puncture in, 39
meninges, fibro-plastic tumour of,
308
palsies, 30
suppuration, 87 et seq.
Cerebro-spinal fluid —
Cytological indications in meningitis.
Direction of flow ot, 10, 18
Examination of, by lumbar puncture,
57.-59
Origin and composition ot, 18
Protective function of, 14-15
Cerebroma, 158
INDEX
399
Cerebrum —
Left hemisphere, functions of, 287-
Right and left hemispheres in develop-
ing brain, 289
Tuberculosis of, 354-362
Tumours of —
Localising symptoms of, 290-296
Surgical intervention in, 294-296
Cestan and Lejeune, case of, quoted, 319-
320
Chance and Spiller, case of, quoted, 275
Charcot, case of, cited, 117
Charcot's motor graphic centre, 311
Charpy, cited, 9
Cheyne and Sutherland, cited, 79
Chipault, cited, 72, 166, 213, 215, 224,
342-343
Cholesteatoma vera, 158 j of cerebellum,
160
Choroid plexus —
Purulent infection of, 96
Tubercule of, 61
Church, cited, 371
Cisterna magna, distension of anterior
part, 12-14
Claytor, cited, 90
Collier, Dr. James, cited, 81, 293, 362
Colman, Dr., case of, quoted, 254
Colman and Ballance, 355
Colour recognition, 297
Coma, 56
Conjugate deviation in cerebellar tumour,
247
Consciousness, loss of, 249
Constipation, 55
Convulsions, 56
Convulsions followed by motor agraphia,
case quoted, 312-313
Co-ordination, cerebellar control of, 241-
243
Corpora quadrigemina, 241
Corpus callosum, lesions of, 349, 365
Corpus striatum, tumours of, 291
Cortex of cerebellum, functions of, 242
Cortical lesions, symmetrical, 351
Cranial bones, brain abscess from local
disease of, 92 et seq.
Cranial nerves, tumours involving, 267,
268, 271, 272, 273
Cranium, tumours of, causing brain
symptoms, 211-221
Critchett, Sir Anderson, cited, 193
Crus, 242
Cruveilhier, cited, 105, 263, 265 ; cases
of, quoted, 216-218, 225, 226
Cunningham, Prof., quoted, 287-290
Cushing, cited, 30 ; intermuscular de-
compressive operations of, 172
Cutaneous sensibility, brain centres for,
.330-331
Cystic angio-sarcoma of centrum ovale.
Cystic glioma of occipital lobe, 303-305
Cysts of brain, 159
Cerebellar, 266
Malignant, 355
Operations for, 169
Serous cysts of arachnoid, 25-26
da Costa, Dr., 371
Dana, cited, 248
Dawkins, Prof. Boyd, cited, 288
Dawson, Dr. Wilfred, 303
Deafness, 248
Deep reflexes in subdural hematocele,
22-25, 29 ; in cerebellar tumour,
233
Deiters' nucleus, lesions of, 237, 238
Dejerine, cited, ii8
Delusions, 167, 351
Dementia, 292
Dercum and Keen, case of, quoted, 368-
. 369 .
Diadocokinesis in cerebellar tumour,
236
Dimness of vision in cerebellar tumour.
Dream state in temporo - sphenoidal
abscess, 1 10, 1 19-12 1
Dudley, Dr., case of, quoted, 202
Dupre and Devaux, case of, quoted, 161
Dupuytren, ^woffi^, 149-150
Dura mater, tumours of, 211-212, 214-
216, 218
Durante, cases of, cited, li^i\ - 245 ;
quoted, 214-215, 224
Duret, cited, 202, 232, 332, 333 ; quoted,
241-243, 364-365
Ear disease, brain symptoms with, 93,
Embolism, brain abscess diagnosis from,
137-138
Encephalocele, 10 et seq., 35
Enchondroma of cranial bones, 211
Endothelioma, meningeal, 212 j cere-
bellar, 265, 269 ; of frontal region,
218 j of temporal lobe, 161
Enteric fever, symptoms simulating those
of meningitis in, 59
Epileptic fits —
Cerebral tumour, in, 293-294
Cortical irritation, from, 315-316
Jacksonian, 239
Recurrent ;arcoma of dura mater,
following, 215
Traumatic, 31
400 SURGERY OF THE BRAIN
Epiblastic tumours, 158
Epithelioma, 158; of frontal region,
218-221
Equilibrium —
Disturbances of, in cerebellar tumour,
234-236
Reflex arc for, 241-242
Ethmoidal suppurative disease, operation
in, 63-65
Extra-dural suppuration, 41-42
Falx cerebri, 16
Ferrier, Dr., cases of, 179, 195, 232-233,
292
Ferrier, Dr., and Dr. Purves Stewart,
cases of, quoted, 188-192, 354-359
Fibro-plastic tumours, 263
Fibro-sarcoma —
Cerebellar meninges, of, 216-218,
225, 264 J successful operation on
adult, 276-282
Cerebellum, of, 275
Large, of parietal lobe, 369-371
Meninges, of, 212
Fibroma of meninges, 212 ; of cerebellum,
271
Fits—
Cerebellar, 248-249
Cerebral, 291-293
Diagnosis of brain tumour, in, 176
Frontal lobe tumours, in, 311
Occipital tumour, in, 302
Sensori-motor aura of, in parietal lobe
tumour, 339-390
Fitzwilliams, Dr., notes of cases by,
263
Forced movements in cerebellar tumours,
249
Forced rotation, 238
Fothergill, Dr. John, 3
Fracture of skull in infants, 34-35
Fraenkel and Hunt, case of, 272
Fraenkel, Hunt, Woolsey, and Elsberg,
case of, 273
Frazier, Dr. Charles, cited, 271, 286
Frontal bone —
Cavernous angeioma of, 213-214, 223
Operation for brain abscess following
disease of, 140-146
Sarcoma of orbital part displacing
dura and brain, 214, 223
Frontal lobe —
Abscess in, loi, 129 ; point of attach-
ment to dura, 144
Angio-sarcoma of, following punctured
fracture of skull, case of, 203-205 ;
histology of case, 206-210
Encysted abscesses of, loi
Glioma of, 159, 202-203
Frontal lobe, cont. — ■
Hydatid of, 166
Motor areas and centres of, 309-311
Tumours of —
Cases quoted, 316-^29, 348-349
Localising symptoms of, 310-316
Frontal region —
Decompressive operation for tumour
of, 170
Endothelioma of meninges in, 218,
227
Epithelioma of, 218-221, 227, 229
Frontal sinuses. See Sinuses
Frontal sinus suppuration, treatment of,
63, 64
Fusiform lobule, lesions of, 300
Gait—
Cerebellar tumour in, 235-236
Cholesteatoma vera of cerebellum, in
case of, 160
Occipital tumour, cerebellar gait in,
302
Garrod, Dr., case of, quoted, 257
Glioma —
Cerebellum of, 233, 236-237
Differentiated from sarcoma, 363-364
Frontal lobe of, 159, 315- 320 j
sections of, 315
Fourth ventricle, filling, 270
Occipito-parietal region of, 305-306
Partial removal of, from brain, gain
after, 168-169
Glio-sarcoma, 158 5 origin of, 363-364 j
of frontal lobe, 321
Godlee, Mr., 33
Goldmann, Prof., cited, 206
Goodhart, Dr., case of, 159
Gowers, Sir William, cases of, 186-188,
300, 316-317, 322
Green, Dr. Charles, 206, 231
Gulliver, Dr., case of, 266
Gummata of brain, 159; spontaneous
disappearance of, 181
Gunn, Mr., 190, 304
Guthrie, quoted, 175
Hadden, Dr., case of, 178, 182
Haemorrhage —
Cerebral hemisphere, tearing up, 263-
264
Diagnosed from brain abscess, 137-
138 5 from brain tumour, 293
Subdural, 19 et seq.
Hallucinations of hearing, 167, 351
visual, 300
Hamilton, M'Lane, cited, 121
Hawkins, Dr., case of, 184-185
INDEX
401
Headache —
Cerebellar tumour in, 231
Cerebral tumour in, 174, 294
Frontal lobe tumour of, 314-315
Intermittent, 28, 31
Meningitis of, 55-56
Persistent, 315, 318
Hearn, Dr., 371
Hematocele of subdural cavity, symptoms
and cases, ig et seq.
Hemianaesthesia, iii, 336
Hemianopsia — •
Complete, 298
Diagnostic value of, 238, 300, 336
Homonymous lateral, 297
Hemiplegia, 36, 137, 336
Henschen of Stockholm, cited, 297-299
Hernia cerebri, 35-38
Hewitt, Prescot, cited, 27-28
Hildesheim, Dr., cited, 82
Hill, Leonard, quoted, 1 1
Hinsberg, cited, 75 ; quoted, 84
Hippocampal lobule, tumour of, 122
Hitzig, cited, 314
Holmes, Dr. Gordon, sections by, 315
and Dr. Grainger Stewart, cited,
248, 249 j quoted, 245
Hooper, cited.^ 105
Horsley, Sir Victor, cited, 168, 195, 238,
313
Hydatid of brain, 169-170 j of spinal
cord, 170
Hydrocephalus —
Brain abscess complicated with, 134-
135 .
Congenital, 80-82
Intradural drainage for, 79-80
Hyperacusia in temporo-sphenoidal ab-
scess, 122-125
Hyperaesthesia, 56
Hyperpyrexia, 169-170
Hysteria simulating meningitis, 57, 59-
60
Imbert, quoted, 14-15
Inco-ordination, localising value of, 369
Infection, intra-cranial —
Pathology of, 41-53
Process of, 92-96
Inferior parietal lobule, lesions of, 332,
342-343
Influenza —
Brain abscess following, 89
Suppuration in subdural cavity in, 50
Injury to head —
Abscess resulting from, 88, 102
Tumour growth in relation to, 200-
210
Insane, the, brain tumours in, 218
Insanity from cerebral injury, 28
Intermuscular decompressive operations,
172
Internal capsule : —
Involved in tumours of parietal
region, 336
Lesion of, 349
Pressure on : in temporo-sphenoidal
abscess, iii 5 relief of, 170
Internal carotid artery, aneurism of, 167
Intra-crani.il inflammation, diagnosis of,
57
Intra-cranial tension : —
Relief of, in inaccessible brain
tumours, 170-172
Symptoms of, alteration of, 174
Litra-cranial tumours, symptoms leading
to wrong diagnosis in, 362
Intra-dural drainage in relief of internal
hydrocephalus, 79-80
Intra-parietal sulcus, 330
Isthmus cerebri, protective mechanism
for, 15-16
Jackson, Dr., cited, 248
Jackson and Beevor, case of, cited, no
Jacksonian epilepsy, 339
Keen, cited, 79; cases of, cited, 321 ;
quoted, 321, 372
Kernig's sign, 56
Key and Retzius, researches on sub-
dural and sub - arachnoid spaces,
9-12
Killian, cited, 64 ; Killian operation, 69
Knecht, case of, quoted, 318-319
Knee-jerk, absence of, 57
Knowles, Miss, case of, 160
Korteweg, case of, 342-343
Kiimmel, cases of, cited, 73-75, 102
Langstafi-', G., 264
Lateral sinus, involved in cerebellar
abscess, 134
Lateral ventricle, hydatid of, 166
Lebert, cited, 100, 105 j cases of, 308 j
fibro-plastic tumour of, 159
Lees, Dr., case of, 249-250
and Sir Thomas Barlow, cited,
12-14, 76
Lemos, case of, 339-340
Lettsom, John Coakley, reminiscences
of, 1-9
Liepmann, quoted, on apraxia, 333-334;
case of, quoted, 343-349
Lister, Mr. W. T., 195, 196
Lloyd and Gerson, case of, 274
Luciani, cited, 239, 240, 246
2 D
402 SURGERY OF THE BRAIN
Lumbar puncture —
Brain injury and apoplexy, in, 39 et seq.
Diagnostic value of, 50, 54
Examination of cerebro -spinal fluid
by, 57-59
Intra - cranial pressure, in relief of,
195-196, .199
Meningitis, in, 46-49
Lungs, brain abscess secondary to dis-
ease of, 90 ; cases quoted, 91-92
Lunn, Mr., 202 5 case of, 276-282
Lyon Medicale, 1904, cited, 90
MacConnell, J. W., case of, 312-313
MacHill, cited, 169
Majendie, cited, 247
Malignant tumour of brain, gain after
partial removal, 168-169
Manasse, cited, 95
Marantic thrombosis of sinuses, dia-
gnosed from brain abscess, 137
Marchand, case of, 306-307
Masnata, case of, 243-244
Mastoid suppuration, 48-49
Mastoidectomy, 69-70
Medulla, tumours of, 365
Melancholia, 293
Meninges —
Adhesions of, 95
Cerebellar, tumours of, 263, 264, 269,
274, 276-282
Fibroma or endothelioma of, operation
for, 168
Tumours of, causing brain symptoms,
Zll et seq.
Meningitis — •
Acute, 42
Brain abscess, complicating, 133-134
Differential diagnosis, 57-60
Diffuse, from direct infection, 93
General suppurative, surgical inter-
vention in, 73-76
Non-tuberculous suppurative, 61
Posterior basal, distension of cisterna
magna with pus in, 12-14
Posterior basal, of infants, 60, 61 ;
operations in relief of, 76, 83-85
Recovery after, possibility of, 61-62
Serosa, 46
Suppurative, 45
Surgical treatment of, 62-70
Symptoms and diagnosis, 54-61
Tuberculous, 60-61 ; diagnosis from
brain abscess, 136; treatment of,
70-73
Varieties of, 53-54
Meningo-cortical abscess, 88, 89, 102
Meniere's disease, vertigo of, 232
Mery and Armand Delille, cited, 61
Mesoblastic tumours, 159
Meyer, R., case of, 92
Middle cerebral peduncle, 242
Mikulicz, case of, 220-221, 229
Mikulicz and Braun, cited, 211
V. Millingen, Dr., 267
Mills, cited, 112, 295, 296, 311, 313,
314; quoted, 330-331 J cases quoted,
271,369-371
Mind blindness, 332
Motor agraphia, diagnostic significance
of, 311, 312-313
Motor aphasia, 311, 313
centres of frontal lobe, 309-311
Mortillet, M. G. de, cited, 289
Mott, cited, 18
Munro and Kelly, cited, \J
Muscular sensibility —
Brain centres for, 330-331
Loss of, in parietal lobe tumour, 340-
341
Naming centre —
Existence of, authorities quoted on,.
n8-i 19
Paralysis of, 1 1 1
Site of, cases suggesting, 112-114,
154-155
Nasal accessory cavities, treatment of
chronic suppuration in, 63-64
Nervous centres, symptoms of disturb-
ances of, 174-175
Neurofibroma, 271, 273
Neiv York Med. Jcurn., cited, 249
Nonne, «>«^, 182, 184; cases of, 182-
189
Nucleus dentatus, lesions of, 237-238
Numbers, brain centre for, 305
Nystagmus, 232, 238 ; in cerebellar
tumour, 247-248
Occipital fossa —
Bulging of, 250
Case presenting symptoms of gross
disease of, 188-192
Tumours of, 230
Occipital lobe —
Cystic glioma of, 202
Decompressive operation for glioma
of, 171-172
Localising symptoms of tumour of,
297-302
Postero - external region, abscess in,.
129
Visual centres in, 297
Tumour cases, quoted, 303-307
Ocular palsy, 36, 39
Okada, cited, 127
INDEX
403
Ophthalmoplegia, 39
Optic neuritis —
Cerebellar tumour, in, 233, 247
Cerebral hematocele, in, 22, 24-25 ;
cerebral tumour, in, 174, 294
Diagnostic value of, 176-177
Meningitis, in, 48, 61
Optic radiation fibres, lesion of, 297,
298, 301-302
Optic thalamus, tumours of, 172,242,291
Orcein and thionin, sections stained by,
2d6, 207, 209
Orientation sense —
Cerebellar disease, in, 238
Reflex centre for, 241, 300
Osteoma of cranium, 211
Otitis with palsy, 136
Otorrhoea, purulent, associated with
tuberculous meningitis, 136, 137
Pacchionian bodies, 10
Pagano's experiments, 239-240
Paget, Sir James, quoted^ 373
Palaeolithic drawings and right-handed-
ness, 288, 289
Palate, weakness of, 248
Paracelsus, quoted, 62
Paralysis —
Arachnoid haemorrhage, in, 29
Cerebral, 28-30
Face, of, 248
Intermittent, 28
Meningitis, in, 56
Tempore -sphenoidal abscess, associ-
ated with. III
Parietal lobe : —
Anatomical points, 330-331
Tumours of, symptoms of, 331-336 ;
cases quoted, 336-355 ; large tumours,
368-371
Parkin operation in posterior basal
meningitis, 76
Peritonitis, suppurative, 53 5 tuber-
culous, 71
Perivascular canalicular system, 18-19
Pia mater —
Inflammation of, 50
Sarcomatous nodules in, 204, 206-207
Suppuration of, 43
Piorry, quoted, 116 note
Pitres, quoted, n8
Pitt, Newton, cited, 93
Pituitary body, tumours of, 291
Pneumonia simulating meningitis, 59
Politzer, Prof., 267
Pons, 242 ; tumours of, 365
Pontine nucleus, 241
Post-parietal gyrus, tumour involving.
Preindlsberger, case of, 214, 223
Preysing, cited, 95 ; case oi, quoted, 114-
Psammoma, 159
Psychic functions, centre for, 311, 313
symptoms of meningitis, 56
Pyaemia complicating brain abscess, 134
Pyaemic abscess of brain, 88-89
Pye-Smith, Dr., cited, 195 ; case of,
quoted, 91-92
Quincke, cited, 43
Raymond, Professor, case of, quoted, 338-
339
Red nucleus, 241, 242
Reflexes, exaggeration of, 56
Right-handedness, antiquity of, 287-290
Rolando, fissure of, 309, 313 5 localising
tumour symptoms in area of, 359
Romberg's sign in cerebellar tumour,
235 5 in occipital tumour, 302
Roncali, cited, 102, 214, 224, 245 ;
quoted, 245-247; case of, quoted,
122-125
Rontgen rays, brain tumour localised
by, 371 _
Ross and Bastian, cited, 1 1 1
Rotation, in lesions — of lateral lobe, 239,
248 ; — of vermis, 240, 248
Russell, Dr. Risien, cited, 236, 247, 248 ;
case of, 303-305
Salzer, case of, cited, 95
Sanger, cited, 182, 207
Sarcoma —
Brain, secondary, 163 ; gain after
partial removal of, 168-169
Cerebellar meninges, of, ,274
Cranial bone, of, 211
Differentiated from glioma, 363-364
Dura mater, of, 21 1-2 12, 214-216
Frontal lobe, perforating dura and
skull, 324-329 ; frontal meninges,
319-320
Large-sized, in fronto-parietal region,
366 - 367 ; in cerebral meninges,
367-368 ; with absence of striking
localising symptoms, 368-369
Sawicki, cited, 213
Scalp —
Carcinoma of, 211
Concavity of, showing complete re-
covery, 257, 282, 283
Convexity of, showing persistence of
abnormal conditions, 191, 199, 282,
322
Flap, method of making, 355
404 SURGERY OF THE BRAIN
Scurvy causing hasmorrhage, 362
Sensation —
Cerebellar tumour, in, 232
Loss of, from cortical lesion, 338-339 ;
from parietal lesion, 341
Sensory cortical symptoms in parietal
lobe tumour, case quoted, 336-338
Serous cysts of arachnoid, 25-26
Singer, Dr., notes of case by, 186-188
Sinuses — -
Accessory, relation to base of skull,
Frontal, suppuration of, 64 \ relation
to frontal lobe, 65
Sixth nerve paralysis, 248
Sharkey, case of, 268, 269
Shattock, Mr., cited, 69, 264
Sherrington, Prof., 172
Shipman, Dr., case of, 203-205 ; his-
tology of, 206-210
Skew deviation in cerebellar tumour,
247
Skull, fractured, with laceration of brain,
282-285
Smell, sense of, cortical localisation of,
1 19-125
Smith, Sir Thomas, cited, 33
Souques, case of, 305-306
Spasticity of limbs, 245
Specific fevers, brain abscess complicating,
88-90
Speech, motor centre for, 311
Spiller, v., case of, 341-342
Squama, periosteal sarcoma of, 212-213,
222
Starr, cited, 89 ; quoted, 372
Starr and M'Cosh, case of, quoted, 340-
Stereognostic perception —
Brain centre for, 330-331
Impairment of, in parietal lobe tumour,
340-342
Stewart, Dr. Grainger, cited, 314
Dr. Purves, cited, 185, 195
and Dr. Ferrier, case of,
354-359
Stoll, cited, 90
Sub-arachnoid space —
Anatomical characters, 9-10
Capacity of, 1 1-12
Drainage of, in tuberculous and sup-
purative meningitis, 72, 73-75
Interchange of fluid between venous
system and, 10
Protective function of, 15-16
Tuberculous disease in, 72
Subdural cavity —
Anatomical characters, 9-10
Capacity of, i i
Subdural cavity, cant. —
Hematocele of, symptoms and cases,
1() et seq.
Subdural hasmorrhage in the new born,
30-31
Superior parietal lobule, lesions of, 348-
349
Swain, case of, cited, 96
Swallowing, difficulty in, 248
Sylvian lake, 72
Syme, Mr., cited, 34
Syphilitic tumour of brain —
Removal of, 168
Spontaneous recovery of, 181
Tache cerebrale, 56
Taylor, Dr. James, cases of, 131, 185-
186, 292
Tegmen tympani, 42, 48, 96
Temperature in subdural hasmorrhage,
29
Temporal bone, abscess secondary to
disease of, 104, 140-146 ; operation
in suppuration of, 63, 64
Temporal lobe, tumours involving, 161,
238
Temporo-sphenoidal lobe —
Abscess of —
Aural origin, of, 103-105
Drainage of, 98
Latency of symptoms in, 129
Localisation symptoms, 109-111;
cases illustrating, 119-125
Multiple, 102-103
Point of attachment to dura, 143
Centres in, 119
Temporo - occipital lobe, topographical
memory centre in, 299
Tenderness on pressure or percussion,
232, 233, 291
Tentorium cerebelli, i6, 17
Third nerve paralysis, 1 1 1
Thrombosis diagnosis from brain abscess,
137-138
Tinnitus, 248, 249
Titubation, 238, 246-247
ToUemer, Louis, cited, 232 ; quoted,
241
Tongue, deviation of, 248
Tonic spasms, 249
Topographical memory centre, 299-300
Touche of Brevannes, cited, 299-300
Toxins, absorption of, simulating menin-
gitis, 57
Trigeminal neuralgia and anaesthesia,
248
Trousseau, cited, 116
Tubercle of the choroid, 61
Tuberculous abscess of brain, 89
INDEX
405
Tuberculous tumours of brain — •
Cerebellum, in, 264-266
Cerebrum, in, 354-362
Meninges, of, 212
Removal of, 168
Spontaneous disappearance of, 181,
186
Tumour of Brain —
Clinical evolution of, 177-179
Cranial nerves, involving, 272, 273
Exploratory operations in, Frazier on,
286
Inaccessible, decompressive operations
for, 170-172
Inquiry in relation to, 200-210
Insane persons, in, 21S
Large size, of, 363-365 ; cases quoted^
366-371
Localisation of, 175-177
Malignancy of, 316
Morbid anatomy of, 158
Operations for, 168-172
Advisability of operation in two
stages, 304-305
Prognosis in, 157-158
Results discussed, 157
Rontgen rays, localised by, 371
Scope of term, 158
Spontaneous disappearance of symp-
toms, 18 1 -19 9
Symptoms and diagnosis, 173-177
General and localising, 175-177,
181
Latency of symptoms, 177-179
Syndrome symptoms without
tumour, 181-182; cases quoted,
182-199
Tunica vaginalis, 20
Turner, Dr. Aldren, case of, 359
Turtle, sub-arachnoid space in the, 19
Tympanum, 42
Unsteadiness of movement in cerebellar
tumour, 231
" Urine caster," 5
Urine, incontinence of, in frontal lobe
tumours, 320, 324
Vascular tumours, 159
Vegas, Herrera, cited, 169 ; quoted, 166
Vertigo, 231-232, 238, 249
Vestibular nerve, lesions of, 238
Visual centres, cortical localisation of,
297-300
Voisin, cited, 117 ; case of, quoted, 116-
117
Vomiting, 28, 29, 55, 174, 231
Watson, Sir Thomas, cited, 17
Weisenburg, cited, 271
Wernicke hemianopic pupillary reaction,
diagnostic value of, 301-302
White matter, resistance to bacterial
action, 94
Whytt, Robert, cited, 6 1
Willis, Thomas, quoted, 44-45
Wilson, Sir Daniel, quoted, 288
Winslow, cited, 117
Word blindness, 298
Word deafness, 351
Zajaczkowslci of Poland, case of, quoted,
213-214, 223
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